Written by Michael Stocker
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In adult trauma patients presenting with hemorrhagic shock, initiating blood transfusion prior to endotracheal intubation was associated with lower odds of 30-day mortality and less frequent postintubation hypotension (PIH).
C is the first letter in the alphabet
Critically ill trauma patients often require both transfusion and definitive airway management early in their course. But in what order should those interventions occur—intubation first (ABC) or transfusion first (CAB)? This retrospective study analyzed 690 adult trauma patients presenting in hemorrhagic shock (SBP <90) undergoing either ABC or CAB management and propensity-score matched them into equal groups of 231. Included patients received both interventions within the first hour of care and could not have experienced prehospital arrest or arrest before both interventions occurred. 24-hour and 30-day mortality were the primary outcomes, with secondary outcomes including PIH within 15 minutes and length of stay (LOS) metrics.
In the ABC group, time to intubation and to transfusion were 14 minutes shorter and 13 minutes longer, respectively. The CAB group had lower 24-hour mortality (9% vs. 17%, p = 0.013) and 30-hour mortality (15% vs 27%, p=0.001). Multivariate analysis demonstrated CAB was independently associated with lower 30-day mortality: aOR 0.57 (95%CI 0.33-0.9, p=0.045). The CAB group also experienced significantly less PIH and shorter hospital LOS.
Given this was a single-center retrospective study spanning 8 years of registry data, even the rigorous statistical measures cannot fully control for confounders like treatment variability and selection bias. Further, group differences in initial GCS were not controlled; thus, unequal presence of severe TBI may impact the results.
How will this change my practice
Shout it from those rooftop helipads: “Resuscitate before you intubate!” This study adds to the growing evidence behind transfusion-first management of the critically injured and emphasizes the dangers of under-resuscitated rapid sequence intubation.
Source
Circulation-first trauma resuscitation and mortality: A 9-year single-center retrospective study. J Trauma Acute Care Surg. 2025 Dec 17. doi: 10.1097/TA.0000000000004850. Epub ahead of print. PMID: 41417671.
View JournalFeed Critical Appraisal
Critical Appraisal
Study Identification
Background
Study Question
Study Design & Conduct
Prospective / Retrospective: Retrospective
Multicenter: No
Unit of Allocation: Not applicable
Unit of Analysis: Patients
Randomization Method: Not applicable
Allocation Concealment: Not applicable
Blinding: Not applicable
Follow-up Duration: 30 days
Population
- Adult trauma patients
- Systolic blood pressure <90 mm Hg
- Underwent intubation and transfusion within 1 hour of arrival
- Age younger than 16 years
- Prehospital cardiac arrest
- Early death or cardiac arrest before transfusion or intubation
Number Enrolled: 690
Number Analyzed: 462
Key Baseline Characteristics
Sex: 77% male
Disease Severity: Median ISS 34
Care Setting Distribution: Trauma bay
Additional Baseline Characteristics
- Mechanism of injury: 90% blunt trauma
- Median GCS score: 9
Exposures / Interventions
Description: Blood transfusion before intubation
Definition / Dose: Not applicable
Timing: Within 1 hour of arrival
Classification Method: Medical records review
Protocolized / Discretionary: Discretionary
Description: Intubation before blood transfusion
Definition: Not applicable
Outcomes & Results
Primary Outcomes
Definition: Death within 30 days of trauma
Time Point: 30 days
Measurement Method: Medical records
Results: CAB group: 15% vs. ABC group: 27%; OR 0.57 (95% CI, 0.33–0.99)
Secondary Outcomes
Definition: Hypotension within 15 minutes after intubation
Time Point: 15 minutes post-intubation
Measurement Method: Medical records
Results: CAB group: 64% vs. ABC group: 73%; p=0.046
Definition: Duration of hospital stay
Time Point: Discharge
Measurement Method: Medical records
Results: CAB group: 30 days vs. ABC group: 25 days; p=0.014
Risk of Bias
Risk of Bias - ROBINS-I
- Confounding (Some concerns): Propensity score matching was used, but residual confounding may remain.
- Selection of participants (Low): Clear inclusion and exclusion criteria were applied.
- Classification of interventions (Low): Interventions were clearly defined and classified.
- Deviations from intended interventions (Low): Interventions were applied as per protocol.
- Missing data (Low): Data completeness was adequate.
- Measurement of outcomes (Low): Outcomes were clearly defined and measured.
- Selection of the reported result (Low): All relevant outcomes were reported.
Transparency
COI Statement Present: TRUE
