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.

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.

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.