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

Abstract

Trauma is a leading global cause of death and disability, with nearly 90% of fatalities occurring in low- and middle-income countries (LMICs), where prehospital care, infrastructure, and trained personnel are limited. This narrative review synthesizes literature (2019-2025) on the initial management of adult polytrauma, and explores strategies to adapt global guidelines in resource-constrained settings. Contemporary frameworks such as advanced trauma life support (ATLS) and World Health Organization essential trauma care emphasize context-sensitive sequencing, permissive hypotension, balanced transfusion, damage-control surgery, and integration of point-of-care ultrasound. Adjuncts including tranexamic acid, viscoelastic-guided transfusion, prehospital whole blood, and selective aortic balloon occlusion offer incremental survival benefits. However, widespread barriers-training deficits, blood bank shortages, lack of imaging, and absent trauma registries-impede implementation. Emerging models demonstrate that scalable solutions such as primary trauma care courses, phased ATLS rollouts, hybrid emergency rooms, and tablet-based registries can reduce mortality and referral delays without requiring wholesale adoption of high-income systems. Meaningful progress requires adapting evidence-based guidelines to local realities, supported by investments in education, diagnostics, transfusion logistics, and national surveillance. Future work should quantify cost-effectiveness and refine context-specific frameworks to close the outcome gap in LMICs.

Key Words: Guideline implementation barriers; Trauma systems; Low- and middle-income countries; Primary trauma care; Massive transfusion protocol; Damage-control surgery; Polytrauma resuscitation

Core Tip: This narrative review synthesizes updated global guidelines on early polytrauma management and explores practical, scalable strategies for adapting these recommendations to low- and middle-income countries (LMICs). By integrating context-sensitive clinical priorities-such as circulation-airway-breathing sequencing in exsanguination, permissive hypotension, balanced transfusion, damage-control surgery, and point-of-care diagnostics-with phased system reforms in training, referral networks, and trauma registries, LMICs can significantly improve survival without requiring wholesale replication of high-income trauma models.

INTRODUCTION

Trauma remains a leading cause of mortality and disability worldwide, particularly among younger populations. According to the Global Burden of Disease Study, trauma accounts for approximately 4.4 million deaths annually, with the majority occurring in individuals aged between 5 years and 29 years[1,2]. Notably, nearly 90% of all trauma-related deaths occur in low- and middle-income countries (LMICs), where disparities in healthcare infrastructure, prehospital care, and trauma system organization are significant[3].

In Vietnam, trauma has consistently ranked among the top contributors to premature death. National data and reports from tertiary referral hospitals indicate that road traffic injuries, domestic accidents, occupational hazards, and interpersonal violence constitute the most frequent mechanisms of injury[4-6]. Recent estimates suggest that trauma-related deaths in Vietnam account for approximately 9% of all-cause mortality, with road traffic accidents alone causing over 20000 fatalities annually[4]. These figures underscore the disproportionate burden of trauma on LMICs, where access to structured emergency care is often limited or inconsistent[7].

A substantial proportion of trauma-related deaths in LMICs occur within the first hour post-injury, commonly referred to as the “golden hour”. This critical period is often lost due to delayed recognition of life-threatening conditions, insufficient prehospital triage, a shortage of trained emergency personnel, and the absence of integrated trauma systems[8,9]. In contrast to high-income countries where multidisciplinary trauma teams, advanced imaging, and real-time surgical intervention are standard of care, the reality in resource-limited settings is starkly different[10].

To address this gap, international organizations have developed standardized guidelines aimed at improving trauma outcomes. Among these, the advanced trauma life support (ATLS) program-first introduced by the American College of Surgeons Committee on Trauma (ACS-COT) in 1980-has emerged as the global benchmark for the initial assessment and management of severely injured patients[11]. The program’s systematic airway, breathing, circulation, disability, exposure (ABCDE) approach has been widely adopted and incorporated into national trauma protocols across many countries.

Complementing ATLS, the World Health Organization (WHO) has issued the essential trauma care guidelines, which advocate for the implementation of minimum trauma care standards across all healthcare settings, irrespective of resource availability. These guidelines emphasize pragmatic improvements in facility organization, human resource allocation, and basic equipment procurement, with the aim of reducing trauma-related mortality at minimal additional cost. Despite the existence of these evidence-based frameworks, implementation remains uneven across LMICs, including in Southeast Asia, where structural and operational limitations persist. Variability in access to surgical care, critical care infrastructure, and formal trauma training continues to hinder the delivery of timely and effective interventions.

SCOPE OF THE REVIEW AND SOURCE SELECTION

The present minireview synthesizes updated clinical guidelines and international recommendations on the initial management of adult patients with multiple trauma, with particular emphasis on early assessment, hemodynamic stabilization, and prioritization of surgical intervention. Furthermore, the review examines current challenges in adapting these standards within the LMIC context, and highlights emerging models, educational strategies, and institutional reforms aimed at enhancing trauma care in resource-constrained environments.

This minireview aims to summarize contemporary guidance and evidence (January 2019 to April 2025) on the early management of adult polytrauma, with an emphasis on applicability to LMICs.

Evidence was gathered through three steps: (1) A hand search of cornerstone documents from international bodies-including the WHO, the ACS-COT, and specialty societies such as Eastern Association for the Surgery of Trauma, World Society of Emergency Surgery; (2) A targeted database search of PubMed and Scopus using flexible combinations of three concept blocks-(polytrauma OR multiple trauma), (early resuscitation OR damage-control OR trauma systems), and (developing countries OR LMICs OR Southeast Asia)-restricted to English-language publications; and (3) Snowball sampling of reference lists and forward citations from key systematic reviews, randomized trials, and organizational reports to capture additional relevant sources.

Included items: (1) Presented updated trauma management protocols or clinical data on the initial phase of care; (2) Evaluated resuscitation strategies or surgical interventions pertinent to major hemorrhage control; or (3) Discussed barriers and solutions for trauma-system implementation in resource-constrained settings. Exclusion criteria were: Pediatric-exclusive studies, isolated single-organ injuries, and investigations conducted solely in high-income countries without contextual relevance to LMICs.

No formal risk-of-bias appraisal or quantitative pooling was undertaken, consistent with the purpose of a narrative review. Full texts meeting inclusion criteria were read in depth and mapped into three thematic domains: (1) Updated clinical guidelines; (2) Advances in hemodynamic resuscitation and diagnostic adjuncts; and (3) System-level challenges and adaptive models in LMICs. Key concepts, practice implications, and contextual caveats were extracted qualitatively and are presented descriptively in the review, supplemented by summary tables where appropriate.

Because this study involved analysis of publicly available literature only, institutional ethical approval was not required.

A total of 209 records were identified (191 from databases and 18 from other sources). After removal of 37 duplicates, 172 records were screened by title and abstract, of which 103 were excluded. Sixty-nine full-text reports were sought for retrieval, but 4 could not be accessed due to restricted availability, leaving 65 for eligibility assessment. After excluding 40 articles that did not meet the inclusion criteria, 25 studies were included in the final review (PRISMA flow diagram, Figure 1).

Figure 1  PRISMA flow diagram.

To enhance transparency, we depicted the identification, screening, and inclusion of records in a PRISMA-style flow diagram. This framework was used to clarify the selection process for this narrative minireview, and not as a full systematic review with formal risk-of-bias assessment or meta-analysis.

FRAMEWORKS AND PRIORITIES IN EARLY POLYTRAUMA CARE

Current clinical guidelines for the initial management of adult patients with multiple trauma

The traditional ABCDE approach forms the foundation of trauma resuscitation and is widely adopted in both prehospital and in-hospital settings[12]. Originally introduced through ATLS program, this stepwise framework has been instrumental in standardizing the early assessment of patients with life-threatening injuries[12]. By prioritizing airway protection, oxygenation, circulatory support, and neurological evaluation in a structured sequence, the ABCDE method enables rapid identification and correction of the most immediate threats to life. We purposefully condense core ATLS/WHO elements and then pivot to adaptation levers-what to simplify, what to substitute, and how to stage implementation across resource tiers in LMICs.

The 11^th edition of the ATLS program, officially released by the ACS-COT in 2025, introduces several substantive updates to the established framework for the initial assessment and management of severely injured patients[13]. Among these is the increasing recognition-supported by expert consensus and emerging literature-that the rigid application of the traditional ABCDE sequence may be suboptimal in trauma patients with suspected massive hemorrhage. In such scenarios, the prioritization of early hemorrhage control and circulatory stabilization [i.e., circulation, airway, breathing (CAB) or exsanguinating ABCDE approaches] has gained traction[13,14]. Additionally, there is growing anticipation that the new edition will include tiered implementation frameworks that take into account resource variability across institutions-a particularly important considerations for LMICs.

Complementing the ATLS framework, the WHO’s essential trauma care guidelines[15] provide a set of minimum standards for trauma care that are both context-sensitive and cost-conscious. These guidelines highlight the importance of organizing emergency services, maintaining a baseline inventory of trauma equipment, and ensuring basic surgical capacity at all levels of care. Rather than prescribing complex interventions, the WHO framework focuses on scalable improvements in system organization and provider training, offering a practical roadmap for LMICs to strengthen trauma care delivery despite limited resources.

While the WHO’s essential trauma care guidelines offer a foundational framework for enhancing trauma care in LMICs[15], their implementation has encountered several challenges. A systematic review revealed that, despite dissemination efforts, there was no evidence of guideline implementation in 143 countries, highlighting significant gaps in adoption[16]. Barriers contributing to this include limited funding, uncoordinated administrative efforts, and a lack of human and physical resources, such as technology and equipment[10]. Furthermore, many LMICs face challenges in data management, analysis, and quality, which are crucial for monitoring and improving trauma care systems. The absence of trauma registries and quality improvement programs further hampers the ability to assess and enhance trauma care service[17,18]. Addressing these systemic and resource-related obstacles is essential to realize the full potential of the WHO guidelines in improving trauma care outcomes globally.

In sum, while ATLS provides a structured and globally recognized methodology for trauma resuscitation, the WHO guidelines offer a pragmatic and adaptable foundation for trauma system development in resource-limited environments. Together, these frameworks form a complementary toolkit to guide both clinical decision-making and health system strengthening in the care of patients with multiple traumas.

Emerging resuscitation strategies and critical interventions in early trauma care

However, recent evidence and expert consensus suggest that in patients with suspected massive hemorrhage, the strict adherence to this sequence may not always be optimal[19]. In such cases, a modified approach emphasizing early hemorrhage control and circulatory stabilization-often referred to as CAB-has been proposed[20,21]. This shift is based on clinical data indicating that premature endotracheal intubation in severely hypovolemic patients can exacerbate hemodynamic collapse by reducing venous return and promoting vasodilation through sedation[19]. Therefore, early hemorrhage control, permissive hypotension, and blood product administration are increasingly recognized as critical first-line priorities in patients presenting with signs of hypovolemic shock[14,22].

Over the past decade, the resuscitation of trauma patients has undergone a fundamental transformation. Traditional approaches based on volume-driven fluid replacement have gradually been replaced by physiology-guided, hemostatic resuscitation strategies designed to prevent the development of the lethal triad-coagulopathy, hypothermia, and acidosis. This shift has been particularly impactful in the management of patients with hemorrhagic shock, which remains the most significant cause of early mortality following severe trauma.

A growing body of evidence now supports a series of inter-locking, physiology-driven interventions that collectively redefine early trauma resuscitation. Table 1 distils these innovations-ranging from CAB-first prioritisation and permissive hypotension to balanced transfusion ratios, damage-control surgery, and point-of-care imaging-highlighting their core principles and clinical advantages.

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.

Permissive hypotension

One of the most critical advancements in trauma resuscitation is the adoption of permissive hypotension, a strategy that involves deliberately maintaining a lower-than-normal systolic blood pressure (SBP), typically within the range of 80 mmHg to 90 mmHg, until definitive hemorrhage control is achieved. The rationale behind permissive hypotension stems from evidence demonstrating that aggressive crystalloid resuscitation before hemostasis can disrupt forming blood clots, dilute essential coagulation factors, and exacerbate ongoing bleeding[23,24]. Experimental and clinical studies have consistently shown improved outcomes when aggressive fluid resuscitation is deferred until hemorrhage control is accomplished, making permissive hypotension an integral component of contemporary trauma care guidelines, as clearly outlined in the ATLS manual[12].

Despite its benefits in trauma patients, permissive hypotension has specific contraindications, particularly in individuals suffering from concomitant traumatic brain injury (TBI). In cases of TBI, maintaining adequate cerebral perfusion pressure is paramount to prevent secondary brain injury and improve patient outcomes. Clinical guidelines, including those from the ATLS program and recommendations from the Brain Trauma Foundation, strongly advise against hypotension in TBI patients[12,25]. Specifically, the brain trauma foundation recommends maintaining a minimum SBP of 100 mmHg for patients aged 50 years to 69 years, and at least 110 mmHg for those aged 15 years to 49 years or over 70 years, to optimize cerebral perfusion and reduce mortality[26]. Thus, while permissive hypotension represents a significant advancement and a valuable resuscitation strategy in trauma care, its use must be carefully considered and is explicitly contraindicated in cases involving TBI due to the imperative of maintaining adequate cerebral perfusion and avoiding exacerbation of neurological damage.

In facilities without computed tomography (CT) to exclude TBI, avoid permissive hypotension and target SBP thresholds consistent with brain trauma foundation guidance. Where blood products are limited, minimise crystalloids, expedite haemorrhage control, and prioritise logistics for early group O whole blood if available.

Massive transfusion protocols

Another cornerstone in modern trauma resuscitation is the implementation of massive transfusion protocols (MTPs), which are systematically designed approaches to manage life-threatening hemorrhage[27]. Traditionally defined as the transfusion of ten or more units of packed red blood cells (PRBCs) within 24 hours, or the need for more than four units in one hour with ongoing blood loss, MTPs aim to preemptively address the lethal triad of trauma: Hypothermia, acidosis, and coagulopathy[28]. The rapid activation and delivery of blood products in a balanced ratio have been shown to reduce mortality and improve hemostatic competence in critically injured patients.

Recent evidence strongly supports the implementation of a 1:1:1 transfusion ratio of PRBCs, fresh frozen plasma, and platelets in MTPs, which effectively simulates whole blood resuscitation and optimizes hemostatic competence[28]. This balanced resuscitation approach mitigates dilutional coagulopathy, stabilizes clot formation, and improves early survival, particularly in exsanguinating trauma patients. Furthermore, cryoprecipitate or fibrinogen concentrates are increasingly incorporated into MTPs to correct hypofibrinogenemia, now recognized as a pivotal factor in trauma-induced coagulopathy[29].

However, the indiscriminate use of MTPs can lead to complications, including transfusion-related acute lung injury, hyperkalemia, and immunologic reactions[30,31]. Therefore, viscoelastic testing methods such as thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are increasingly integrated with MTPs to guide targeted hemostatic therapy[29]. By providing real-time insights into the patient's coagulation status, these technologies facilitate a more precise and individualized resuscitation strategy, potentially minimizing unnecessary transfusion and associated morbidity.

Damage control surgery

Among the most transformative advancements in modern trauma surgery is the implementation of damage control surgery (DCS), a paradigm-shifting approach designed to manage critically injured patients who are physiologically exhausted. Originating in the early 1990s, DCS prioritizes rapid control of hemorrhage and contamination, followed by temporary closure and deferred definitive repair once the patient's metabolic derangements, particularly hypothermia, acidosis, and coagulopathy, are corrected[32]. This staged approach has dramatically improved survival rates in patients previously deemed unsalvageable due to the physiological burden of extensive surgical interventions. Recent meta-analyses have demonstrated that DCS significantly reduces mortality [relative risk (RR) = 0.27; 95%CI: 0.22-0.34] and improves rescue success rates (RR = 1.36; 95%CI: 1.29-1.44) compared to traditional surgical approaches[33]. Additionally, DCS is associated with shorter hospital stays and a lower incidence of complications such as disseminated intravascular coagulation multiple organ dysfunction syndrome, and shock[33].

The DCS strategy unfolds in three distinct and interdependent phases[32]. The initial phase involves an abbreviated laparotomy, focusing on immediate hemorrhage control, contamination limitation, and temporary closure of body cavities. Techniques such as vascular ligation, perihepatic or pelvic packing, temporary bowel occlusion, and temporary abdominal closure devices-including vacuum-assisted systems-are employed to achieve swift hemostasis and mitigate ongoing physiological derangement[34]. Following this, patients are transferred to the intensive care unit for aggressive resuscitation. During this phase, targeted correction of hypothermia, acidosis, and coagulopathy is pursued through guided administration of fluids and blood products, active rewarming, and organ support measures. Once physiological normalization is achieved-typically within 24 hours to 72 hours-the final phase is initiated, entailing definitive surgical repair. This includes vascular reconstruction, bowel anastomosis, and formal closure of surgical wounds, aimed at restoring anatomical continuity and functional integrity[32,34].

Clinical evidence robustly supports DCS as a life-saving intervention, especially for trauma patients exhibiting profound shock, severe hypothermia, and coagulopathy[33,35]. The principles of DCS have transcended abdominal trauma, finding applicability in thoracic, orthopedic, and neurosurgical emergencies, thereby highlighting its versatility. Despite its proven benefits, DCS necessitates seamless multidisciplinary coordination and carries potential risks, including intra-abdominal hypertension and prolonged intensive care unit stays, which require vigilant postoperative management[36,37]. Ultimately, DCS signifies a critical paradigm shift from anatomy-driven to physiology-guided trauma care, reaffirming that in severe injuries, systemic stabilization is paramount to patient survival.

Point-of-care imaging and diagnostic adjuncts in trauma resuscitation

In parallel with advances in hemodynamic and surgical strategies, the role of point-of-care imaging has become indispensable in modern trauma resuscitation. Early and accurate identification of life-threatening injuries is critical to guiding timely interventions, and imaging modalities now play a central role in both the primary survey and ongoing clinical decision-making.

The extended focused assessment with sonography in trauma (eFAST) has become an integral component of the initial evaluation of trauma patients[38]. Building upon the traditional focused assessment with sonography in trauma exam, eFAST expands the scope to include detection of pneumothorax and hemothorax, alongside pericardial tamponade and hemoperitoneum[39]. Its non-invasive nature, rapid acquisition, and bedside availability make it especially valuable in unstable patients or in resource-constrained environments where advanced imaging may not be readily accessible[40]. Furthermore, eFAST is instrumental in prioritizing surgical or procedural interventions without the need for transport, thereby reducing delays in definitive care[41].

For hemodynamically stable patients, or those demonstrating a transient response to resuscitation, early whole-body computed tomography (WBCT)-commonly referred to as "pan-scan"-has emerged as a cornerstone in comprehensive trauma assessment[42,43]. Pan-scan imaging provides a high diagnostic yield, identifying occult injuries that may not be apparent on clinical examination or ultrasound[43]. A comprehensive meta-analysis encompassing 27 studies with 68838 trauma patients evaluated the efficacy of WBCT in diagnosing injuries in polytrauma patients. While the pooled odds ratio for mortality was 0.94 (95%CI: 0.83-1.06), indicating no statistically significant difference, the study highlighted WBCT’s role in facilitating faster and more efficient diagnosis for polytrauma patients[42]. The concept of hybrid resuscitation rooms, equipped with in-situ CT scanners, epitomizes this integration, allowing for seamless transition from imaging to intervention without necessitating patient transfer[44,45]. This model has shown to improve both the speed and efficacy of trauma care in select centers.

For hypotensive or transfer-candidate patients at lower-tier hospitals, adopt “image to decide, not to delay”: EFAST, plain films, and predefined transfer triggers; defer CT to the receiving centre. Hybrid rooms are ideal but the principle-rapid decision without transport delays-can be approximated by co-locating ultrasound, blood bank, and operating room readiness.

Despite these technological advancements, judicious application of imaging remains essential, particularly in resource-limited settings. A retrospective analysis from the National Trauma Data Bank revealed that hypotensive trauma patients undergoing preoperative abdominal CT scans experienced significant delays to the operating room, correlating with a 70% higher risk of mortality. Notably, when laparotomy was delayed beyond 30 minutes due to imaging, the mortality risk increased over sevenfold.... It is well established that clinical judgment, supported by eFAST and plain radiography, is often sufficient to guide immediate surgical decision-making. Current trauma guidelines strongly caution against delaying operative management or patient transfer for imaging studies that do not directly influence acute therapeutic decisions. The principle of “image to decide, not to delay” underscores the importance of integrating diagnostic tools with clinical acumen.

Pharmacologic innovations and emerging technologies in trauma care

Beyond hemodynamic control, transfusion strategies, and surgical interventions, modern trauma care has embraced a range of pharmacologic adjuncts and emerging technologies that further enhance survival in critically injured patients. These advancements, grounded in robust clinical evidence and technological innovation, represent the next frontier in comprehensive trauma management.

One of the most impactful pharmacologic interventions is the early administration of tranexamic acid (TXA). The landmark Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH)-2 trial (20211 patients), provided compelling evidence that TXA, an antifibrinolytic agent, significantly reduces all-cause 28-day mortality in bleeding trauma patients when administered within three hours of injury, with the most pronounced benefit observed when given within the first hour, where death due to bleeding fell from 7.7% to 5.3% (RR = 0.68)[46]. While the subsequent CRASH-3 trial did not demonstrate a survival advantage in patients with isolated TBI[47], further high-quality syntheses corroborate that TXA remains a cornerstone in the pharmacologic management of patients with suspected major hemorrhage safety and efficacy[48-50]. A recent systematic review and meta-analysis of 12 studies (12682 trauma patients) showed that pre-hospital TXA lowered 24 hours mortality from 12.0% to 9.7% (OR: 0.72, 95%CI: 0.54-0.94) with no statistically significant increase in venous thrombo-embolism (OR: 1.14, 95%CI: 0.98-1.33, P = 0.09) or other outcomes[51]. The recommended dosing protocol consists of a 1-gram intravenous bolus followed by an infusion of 1 g over eight hours. Timely administration is crucial, as delayed use beyond the recommended window may negate its benefits or even cause harm due to prothrombotic risks[49,50,52].

In parallel, several emerging technologies are being integrated into trauma resuscitation protocols. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has garnered attention as a minimally invasive technique to achieve temporary hemorrhage control in patients with non-compressible torso bleeding[53]. By inflating a balloon catheter within the aorta, REBOA offers a bridge to definitive surgical or interventional radiologic management, particularly in cases of pelvic fractures or abdominal trauma where rapid exsanguination precludes conventional measures[53]. However, recent large-scale analyses show mixed results. A 2021 systematic review of 11 observational studies (5866 patients) found that REBOA reduced adjusted mortality by 62% vs resuscitative thoracotomy (RT) (adjusted OR: 0.38, 95%CI: 0.20-0.74) but conferred no survival advantage over standard resuscitation (adjusted OR: 1.40, 95%CI: 0.79-2.46)[54]. Consistent with this, the multi-centre AAST-AORTA registry (991 patients) showed mortality 79% with zone-1 REBOA vs 93% with RT after propensity matching (P = 0.03)[55]. Yet, when 31 studies were pooled in the 2025 EAST guideline meta-analysis, overall survival was no better than no-REBOA care (OR: 0.86, 95%CI: 0.37-2.04) and mortality increased in blunt pelvic-fracture patients (OR: 2.15, 95%CI: 1.35-3.42), leading the panel to issue only a conditional recommendation against routine use[56]. The first pragmatic randomised controlled trial (UK-REBOA, 90 patients) stopped early because Bayesian analysis suggested an 86.9% probability that REBOA increased 90-day mortality compared with standard care alone[57]. Current guidelines therefore reserve REBOA for highly selected patients, when trained teams are present with balloon-up times kept < 30 minutes based on low-level evidence[56,58].

Another notable advancement is the use of cold-stored whole blood[59] and pre-hospital blood product transfusions[60], which have significantly reduced the time to hemostatic resuscitation, particularly in austere or pre-hospital environments[60-64]. Cold-stored whole blood preserves functional platelets and clotting factors, closely mimicking the physiological benefits of fresh whole blood, while logistical innovations in transport and storage have made its broader application feasible[65,66].

Furthermore, the deployment of point-of-care laboratory testing-including portable assays for lactate, base excess, and viscoelastic parameters such as TEG or rotational ROTEM - enables real-time monitoring of resuscitation effectiveness[67,68]. These diagnostics facilitate the titration of fluid and blood product administration, ensuring a tailored approach that minimizes over-resuscitation and addresses trauma-induced coagulopathy with precision.

Collectively, these pharmacologic and technological advancements reflect a paradigm shift in trauma care, where early, targeted, and physiologically informed interventions converge to optimize outcomes. As research continues to refine the application of these modalities, their integration into standardized trauma protocols is poised to further reduce mortality and morbidity in severely injured populations. The future of trauma resuscitation lies in the seamless blending of established principles with emerging evidence-based innovations, guided by dynamic assessment and multidisciplinary coordination.

DISCUSSION

Challenges in implementing trauma guidelines in LMICs

Despite the availability of evidence-based trauma guidelines-such as ATLS and the WHO essential trauma care framework their implementation in LMICs remains inconsistent and is hampered by multiple systemic barriers[69].

These challenges extend beyond individual clinical practice and reflect inherent weaknesses in health systems, including: Shortages in human resources (both general healthcare personnel and trauma-specialized providers); deficiencies in material resources (diagnostic tools such as computed tomography scanners and therapeutic infrastructure such as blood banks, emergency operating rooms, and postoperative intensive care units); and a lack of trauma care management systems and coordinated referral networks (inadequate infrastructure, fragmented transfer pathways, and limited prehospital coordination)[10,70-73]. These inter-related obstacles are summarised in Figure 2.

Figure 2 Challenges in implementing trauma guidelines in low- and middle-income countries. CT: Computed tomography; ICU: Intensive care unit.

Human resource shortages

Trauma care systems in LMICs face two distinct workforce gaps. First, at the primary healthcare level, many facilities suffer from a critical shortage of healthcare personnel - including nurses, paramedics, and general practitioners - reducing their capacity to promptly identify life-threatening injuries, provide initial stabilization, and coordinate timely referral from the first point of contact. Second, in primary and secondary health centers, most trauma patients are managed by general practitioners or general surgeons without formal subspecialty training in trauma or emergency surgery, resulting in inconsistent adoption of standardized resuscitation protocols and structured decision-making processes[74,75].

Access to standardized training programs such as ATLS remains limited due to high costs, a shortage of certified instructors, and the absence of simulation-based training facilities, leaving most care providers at both primary and secondary levels without formal trauma resuscitation training[74]. To address this gap, alternative models such as primary trauma care (PTC) have been developed and promoted by the WHO as a cost-effective educational framework tailored to resource-limited settings. Unlike ATLS, the PTC course focuses on essential trauma principles using simplified protocols and is often delivered through a “train-the-trainer” cascade to broaden its reach[76,77].

In Vietnam, preliminary implementation of PTC has shown promising outcomes, including improved theoretical knowledge and increased confidence among frontline providers in managing critically injured patients[78], thereby reducing the burden on specialized trauma centers.

Material resource deficiencies

From a logistical standpoint, many district and provincial hospitals lack basic infrastructure and critical resources. These may include the unavailability of point-of-care ultrasound (FAST), CT, dedicated operating rooms for emergency surgery, blood banks with adequate reserves, and postoperative intensive care units[79,80]. In such environments, trauma teams must often rely on clinical acumen and limited diagnostic tools to make high-stakes decisions.

Lack of trauma care management systems and networks

At the system level, the absence of formal trauma systems and national trauma registries hinders care coordination, quality improvement, and policy development. In most LMICs, there is no clearly structured referral hierarchy to determine which facilities should receive high-acuity trauma cases, resulting in the overburdening of urban tertiary hospitals while bypassing capable intermediate centers[70,81].

Factors such as poor working conditions, limited academic recognition, and inadequate compensation discourage medical graduates from pursuing careers in trauma surgery or emergency medicine. Moreover, trauma care remains underrepresented in the undergraduate and postgraduate medical curriculum in several countries, with no formally recognized trauma surgery specialty or residency track in many institutions[9,77]. Building a sustainable trauma workforce will require long-term investments, including the establishment of trauma fellowships, continuing medical education programs, mental health support, and appropriate financial incentives for healthcare professionals working in high-risk environments[82].

Several observational studies have reported that the practice of performing CT scans at lower-tier hospitals-despite limited surgical capability-can delay transfer to definitive care centers by over 90 minutes, with no impact on treatment decisions[83,84]. Consequently, current recommendations emphasize the need to develop context-specific clinical decision pathways that prioritize timely surgical intervention or interfacility transfer over unnecessary diagnostic delays.

Parallel to these workforce and system limitations, the lack of data infrastructure precludes meaningful outcome analysis, impairs surveillance, and undermines evidence-informed policymaking. To address this, the WHO has developed a minimum trauma dataset and monitoring framework designed for implementation in resource-constrained settings[85]. Several countries in Southeast Asia have begun pilot programs using simplified trauma registries managed by emergency department personnel, demonstrating feasibility and utility in benchmarking performance and guiding resource allocation.

In sum, LMICs face a constellation of interrelated barriers to trauma guideline implementation. These include financial, educational, operational, and systemic factors that must be addressed through multi-level, context-specific strategies. While replicating high-income country models may not be feasible, adopting scalable interventions-such as low-cost training initiatives, point-of-care diagnostics, decentralized blood supply systems, and targeted workforce development-can bridge critical gaps in trauma care delivery. Pragmatic solutions should be framed as barrier-solution pairs with simple metrics (e.g., door-to-knife time, proportion transferred without pre-operation CT, PTC completion rates) to address specific implementation challenges more effectively. Ultimately, strengthening trauma care in LMICs requires not only technical solutions but also strong political will, cross-sector collaboration, and sustained investment in system capacity building.

SUCCESSFUL MODELS AND FEASIBLE INITIATIVES IN LOW- AND MIDDLE-INCOME COUNTRIES

Despite facing substantial limitations in resources, infrastructure, and personnel, several LMICs have implemented innovative models that demonstrate the practical feasibility of adapting international trauma care guidelines to local contexts. These success stories provide valuable insights into scalable interventions that can be replicated or modified to improve trauma outcomes in similarly constrained settings.

In Kenya, a national trauma initiative supported by international partners integrated ATLS-based principles into the public health system through structured training and targeted investments in essential trauma care infrastructure. Over an 18-month period, hospitals participating in the program reported a reduction in 30-day trauma mortality from 17% to 6%, primarily due to improvements in early hemorrhage control, protocol-driven resuscitation, and better prehospital coordination[86]. The program’s key components included regular multidisciplinary training, procurement of basic trauma equipment in line with WHO standards, and the establishment of referral protocols between district and tertiary hospitals.

In India, over 7800 healthcare providers have received formal ATLS training in the past decade, supported by the ministry of health and academic institutions[87]. This widespread dissemination of trauma education has coincided with the development of a tiered trauma center network and has prompted neighboring countries such as Nepal, Bangladesh, and Sri Lanka to adopt similar training and certification models[87,88]. India’s experience highlights the importance of sustained governmental commitment, public-private partnerships, and the integration of trauma systems into national health planning as key enablers of successful implementation.

In Vietnam, trauma care historically faced major challenges, especially in pre-hospital settings. A 2006 study in Hanoi revealed that only 4% of trauma victims were transported by ambulance, while over half received no first aid at the scene. The system lacked coordination between emergency centers and hospitals, and emergency medical services met less than 4% of demand[89]. These limitations underscored the urgent need for structured trauma response systems. In recent years, efforts to strengthen frontline trauma capacity have centered on expanding the PTC program. This initiative, supported by international collaborations and led by tertiary centers such as Viet Duc and Cho Ray hospitals, has trained numerous provincial and district hospital staff in early trauma recognition, initial resuscitation, and timely referral[9]. A prospective study showed significant gains in participant knowledge and confidence following PTC training, with theoretical knowledge scores increasing from 60.0% to 77.2%, and confidence levels rising from 59.2% to 71.0%[76]. These improvements were largely sustained at six-month follow-up. Furthermore, organizational reforms such as trauma triage pilots in urban areas have aimed to improve hospital allocation based on severity and resource availability[76]. Though limited in scale, these represent a promising step toward integrated trauma systems in Vietnam.

Beyond education, several organizational reforms have improved trauma care in Vietnam. The Ministry of Health’s 1816 project, launched in 2008, deployed over 4000 central hospital specialists to local facilities, transferring 4800 techniques and reducing referrals[90]. Urban pilot programs have introduced triage systems to guide hospital allocation based on injury severity and resources. These initiatives reflect a broader shift toward coordinated, systems-based approaches to trauma care delivery. In Ho Chi Minh City, the 9999 EMS service applied the ProQA protocol and real-time ambulance-hospital communication, cutting response times[91]. Hanoi has also upgraded emergency departments through international partnerships[92]. Though limited in scale, these reforms mark vital progress toward a national trauma system.

Accurate clinical documentation is critical in trauma care, forming the basis for patient management, quality monitoring, and system evaluation. In high-income countries like Germany and the United States, standardized tools such as electronic health records and trauma checklists have improved survival rates and reduced time to whole-body CT scans[93,94]. These registries track key indicators such as mechanism of injury, vital signs, interventions, and patient outcomes, providing a foundation for performance evaluation and local quality improvement. Despite their simplicity, these tools have enabled administrators to identify trends, advocate for resources, and monitor the impact of new protocols over time. While LMICs lack such infrastructure, initiatives like Uganda’s tablet-based trauma registry show that even simplified digital tools can enhance data quality and inform resource allocation effectively[95].

Common elements across these successful models include flexible training curricula, decentralized implementation, and a focus on high-impact, low-cost interventions. Importantly, none of these initiatives relied solely on imported expertise or expensive technology. Instead, they were built on local ownership, regional collaboration, and context-specific adaptation of global standards. Regional training hubs, such as those established in Singapore and the Philippines, have facilitated knowledge exchange and cross-border faculty development, further expanding the reach and sustainability of trauma education in Southeast Asia[96,97].

In summary, while LMICs face systemic barriers to trauma care optimization, these challenges are not insurmountable. The experiences of Kenya, India, Vietnam, and the Philippines demonstrate that with strategic planning, intersectoral collaboration, and focused investment in human and system capacity, meaningful improvements in trauma care can be achieved-even in settings with limited resources. These representative initiatives are concisely summarised in Table 2 to facilitate comparison of implementation models, core components, and reported impact.

Table 2 Successful models and feasible initiatives for strengthening trauma care in low- and middle-income countries.

Country/region	Key initiative	Core components	Reported impact
Kenya	National trauma programme with ATLS-based training	Multidisciplinary courses; procurement of WHO-recommended equipment; referral protocols linking district and tertiary hospitals[86]	30-day trauma mortality ↓ from 17% to 6% over 18 months[86]
India	Nationwide ATLS roll-out & tiered trauma-centre network	Government funding; public-private partnerships; faculty exchange across states[87,88]	> 7800 providers certified; model adopted by Nepal, Bangladesh & Sri Lanka[87,88]
Vietnam	PTC cascade training & 1816 satellite-hospital project	Low-cost PTC courses; train-the-trainer cascade; deployment of central-hospital specialists; urban triage pilots[9,76,90-92]	Theoretical knowledge ↑ 17%; confidence ↑ 12%; referral delays and ambulance response times reduced[76,91,92]
Philippines/Singapore hub	Regional training hubs & cross-border faculty development	Shared curricula; simulation workshops; ASEAN-wide scholarship & faculty exchange[96,97]	Sustainable, locally led trauma courses now running in ≥ 6 ASEAN countries[96,97]

ATLS: Advanced trauma life support; WHO: World Health Organization; PTC: Primary trauma care; ASEAN: Association of Southeast Asian Nations.

ACTION-ORIENTED FRAMEWORK FOR TRAUMA CARE IMPLEMENTATION IN LMICS

Going beyond general statements, practical adaptation requires structured, context-sensitive actions. Based on evidence synthesized in this review and successful initiatives in Kenya, India, Vietnam, and other LMICs, we propose a pragmatic set of actions that can guide phased implementation. These are not prescriptive recommendations but rather illustrative steps that highlight feasible priorities for health systems operating under resource constraints (Table 3).

Table 3 Practical proposed actions for strengthening trauma care in low- and middle-income countries.

Domain	Key actions
Workforce & training	Expand ATLS, PTC, CME
	Integrate trauma modules in curricula
	Strengthen trauma workforce training & continuous professional development
Rapid diagnostics	Train GPs & EM physicians in eFAST
	Perform eFAST promptly in unstable trauma patients
	Apply the principle of “image to decide, not to delay”, integrating diagnostics with clinical judgment
Hemostatic resuscitation	Administer TXA early
	Activate MTP with 1:1:1 ratio (PRBC:Plasma:Platelets)
	Ensure timely delivery of blood products
Surgical & infrastructure	Maintain 24/7 emergency operating theater
	Ensure local blood bank availability
	Upgrade district/provincial hospitals with essential trauma equipment
Prehospital care	Strengthen ambulance & referral systems
	Train first responders and paramedics in trauma stabilization
	Enhance prehospital assessment and triage
Clinical pathways & data	Implement standardized trauma protocols adapted to LMICs
	Establish national trauma registry
	Ensure completeness of core data for quality improvement

ATLS: Advanced trauma life support; PTC: Primary trauma care; CME: Continuing medical education; GPs: General practitioners; EM: Emergency medicine; eFAST: Extended focused assessment with sonography for trauma; TXA: Tranexamic acid; PRBC: Packed red blood cells; MTP: Massive transfusion protocol; LMICs: Low- and middle-income countries.

CONCLUSION

Trauma care in LMICs requires a structured yet flexible approach grounded in ATLS and WHO frameworks, with emphasis on CAB in exsanguination, permissive hypotension, balanced transfusion, and point-of-care diagnostics. Systemic barriers, including limited training, workforce shortages, and under-resourced infrastructure, still impede implementation.

Scalable solutions such as PTC training, eFAST, structured referral systems, and simplified registries have shown measurable benefits. Experiences from Kenya, India, Vietnam, and the Philippines demonstrate that context-adapted, low-cost interventions, framed as barrier-solution pairs with simple metrics, can drive meaningful progress and reduce outcome disparities in resource-constrained settings.

In practice, LMIC adaptation proceeds via four steps (4S): Summarise core guidance, simplify workflows, sequence by resource tier, and scale with training and data feedback.