Study Suggests Updated Treatment Paradigm of Circulation, Airway, Breathing for Patients with Severe Bleeding
Ferrada P, Ferrada R, Jacobs L., et al. Prioritizing Circulation to Improve Outcomes for Patients with Exsanguinating Injury: A Literature Review and Techniques to Help Clinicians to Achieve Bleeding Control. J Am Coll Surg. 2023, in press.
Accumulating evidence has stimulated trauma surgeons to re-examine the traditional approach to early stage resuscitation (ABC: Airway, Breathing, Circulation) for patients with severe injury and hemorrhagic shock.
Several studies have shown that early efforts to control bleeding and improve circulation using maneuvers, such as those taught in the ACS STOP THE BLEED® program and prioritizing cardiac compressions over early airway control in patients with cardiac arrest, have improved outcomes compared with immediate intubation or mouth-to-mouth/mask ventilation. Authors noted that drugs administered to facilitate emergency intubation reduce the vasoconstrictor response to hemorrhagic shock resulting in worsening of lactic acidosis.
Military and civilian data have shown that improved outcomes have been observed with immediate administration of whole-blood or blood components (packed red cells, plasma, platelets) followed by airway control in severely injured patients.
The authors suggest that a CAB (Circulation, Airway, Breathing) approach be considered in high-risk patients. They emphasized that there are clear indications for prioritizing airway control in select patient groups, such as those with vomiting and signs of airway obstruction/injury.
The evidence presented strongly suggests that trauma resuscitation priorities should be adjusted based on rapid, careful, assessment of the main factors likely to influence outcome (bleeding or hypoxemia). CAB should be the approach for patients with life-threatening hemorrhage.
Examining the Risk of Mortality following Surgery in Patients with a Previous Cardiovascular Event
Chalitsios CV, Luney MS, Lindsay WA, Sanders RD, McKeever TM, Moppett I. Risk of Mortality following Surgery in Patients with a Previous Cardiovascular Event. JAMA Surg. 2023.
Editorial: Graham LA, Hawn MT. Managing Competing Risks for Surgical Patients with Complex Medical Problems-Considering Confounding. JAMA Surg. 2023.
Christos V. Chalitsios, PhD, and coauthors analyzed data from three large national databases to determine the time interval during which risk of surgery is increased due to a prior cardiovascular event (ischemic cardiac event with or without intervention and ischemic stroke). The data included more than 21 million patients (n = 877,430 with a cardiovascular event).
The data analysis showed that mortality risk was increased within the first 11.3 months after a cardiovascular event for patients undergoing elective surgery and 7.3 months for patients undergoing emergency surgery. The shortened risk interval for emergency surgery was likely because the emergent condition was affecting mortality risk more than the prior cardiovascular event.
The authors recommended that these data be used to counsel patients regarding delaying elective surgery for a longer interval than the 6-month delay included in current practice guidelines.In the editorial that accompanied the article, Laura A. Graham, PhD, MPH, and Mary T. Hawn, MD, PhD, FACS, encouraged readers to use these data cautiously because of the chance of significant bias (selection bias-only patients deemed healthy enough to have surgery underwent procedures and immortal time bias-some patients died without undergoing surgery). While these data may be considered in determining the length of the delay interval because of increased risk of surgery due to a prior cardiovascular event, there is insufficient new evidence to change current guidelines.
