Written by Michael Stocker
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.
