Strengthening trauma care in low- and middle-income countries through guideline adaptation and scalable system reforms

Table 1 Key early resuscitation strategies and critical interventions in adult polytrauma

Principle	Brief description	Examples/tools	Key benefits
Early hemorrhage control prioritization (CAB)	Prioritize hemorrhage control and restore circulation before airway management in patients with severe bleeding, replacing the traditional ABC sequence	CAB vs ABC[13,14,19-22]	Reduces risk of hemodynamic collapse from hypovolemia; improves initial survival
Permissive hypotension	Maintain systolic blood pressure at 80-90 mmHg until definitive hemorrhage control to preserve coagulation factors and clot stability	Target SBP 80-90 mmHg[23,24]	Minimizes dilution of clotting factors, limits ongoing bleeding; improves early survival
Balanced transfusion (1:1:1 MTP)	Activate massive transfusion protocol with a 11:1 ratio of PRBCs:FFP:Platelets, supplemented by cryoprecipitate/fibrinogen and guided by TEG/ROTEM	PROPPR trial[28]; TEG/ROTEM[29]	Optimizes coagulation, reduces hemorrhage-related mortality, and decreases transfusion complications
DCS	A three-stage approach: (1) Rapid hemorrhage control and temporary closure; (2) Intensive ICU resuscitation; and (3) Definitive repair once stable	Temporary packing; VAC[32-35]	Significantly lowers mortality and improves survival; shortens ICU stay and reduces complications
Bedside ultrasound (eFAST) & whole-body CT (Pan-Scan)	Use eFAST for rapid detection of free fluid or air, and whole-body CT to identify occult injuries in stable or transiently responding patients	eFAST[38-41]; WBCT[42,43]	Speeds injury localization, reduces time to intervention, and ensures accurate diagnosis without patient transfer
Early tranexamic acid (TXA)	Administer TXA within 3 hours (1 g bolus followed by 1 g infusion over 8 hours) to inhibit fibrinolysis and reduce bleeding	CRASH-2 trial[46]; meta-analysis[51]	Significantly decreases bleeding-related mortality when given early, with highest benefit if within the first hour
Resuscitative endovascular balloon occlusion of the aorta	Deploy an endovascular balloon in the aorta to temporarily occlude blood flow, controlling torso hemorrhage and bridging to definitive surgical or endovascular care	Aortic balloon occlusion[53-57]	Provides rapid hemorrhage control and prolongs survival time until definitive treatment

CAB: Circulation–airway–breathing; ABC: Airway–breathing–circulation; MTP: Massive transfusion protocol; DCS: Damage control surgery; ICU: Intensive care unit; VAC: Vacuum-assisted closure; TEG: Thromboelastography; ROTEM: Rotational thromboelastometry; PROPPR: Pragmatic randomized optimal platelet and plasma ratios trial; eFAST: Extended focused assessment with sonography for trauma; CT: Computed tomography; WBCT: Whole-body computed tomography; TXA: Tranexamic acid; CRASH-2: Clinical randomisation of an antifibrinolytic in significant haemorrhage trial 2.