Chinese expert consensus on the prehospital management of major trauma

Abstract

To standardize the key techniques and protocols of prehospital emergency care for major trauma in China, and to improve the quality and efficiency of treatment, a multidisciplinary panel of experts in emergency medicine, trauma care, and prehospital rescue was organized to form an expert committee and a core working group. This initiative was co-sponsored by the Trauma Emergency and Multiple Trauma Group of the Trauma Society of the Chinese Medical Association, the Youth Group of the Disaster Medicine Society of the Chinese Medical Association, and the Combat and Trauma Care Specialty Alliance of Army Hospitals. The group systematically searched databases including PubMed, Embase, Cochrane Library, Web of Science, China Biology, Medicine, China National Knowledge Infrastructure, Wanfang Data, and VIP Information to collect relevant guidelines, systematic reviews, and clinical studies. Based on evidence-based findings and clinical practice scenarios, the consensus was drafted. Multiple rounds of consultation and voting were conducted, and a consensus meeting was held to resolve any disputed items. Ultimately, 16 recommendations were formulated addressing 14 core clinical questions in the prehospital management of severe trauma. The contents cover scene safety, rapid recognition and early warning of severe trauma, control of exsanguinating external hemorrhage (X), airway management (A), breathing management (B), circulation management (C), disability/neurologic assessment (D), exposure and temperature control (E), trauma in special populations (the elderly), immobilization and extrication, transport decision-making, prehospital-to-hospital handover, teamwork, and systematic training. This consensus strongly emphasizes the "xABCDE" assessment sequence and recommends key interventions such as the use of commercial tourniquets and wound packing for hemorrhage control, permissive hypotensive resuscitation, early administration of tranexamic acid, and the standardized application of pelvic binders. It also advocates the use of standardized communication models for prehospital-to-hospital handovers. This consensus provides prehospital emergency providers in China with a practical, evidence-based set of key techniques and protocols for severe trauma care, which will help promote the standardization of the prehospital trauma care system, support the development of a high-quality national prehospital trauma care system, and ultimately improve patient outcomes.

1. Introduction

Trauma represents a significant global public health challenge, causing over 5 million deaths annually and ranking as the leading cause of death for individuals under 45 years of age.1, 2, 3 Major trauma is characterized by high mortality and disability rates, with its management being highly time-dependent, underscoring that “time is life, time is function".4, 5, 6 As the initial link in the trauma care chain, the efficiency and quality of prehospital care directly determine the final prognosis of patients.⁷ Key interventions during the prehospital phase, including rapid identification, effective hemorrhage control, airway management, and appropriate transport, are central to reducing “preventable deaths” among trauma patients.8, 9, 10

However, a recent global trauma care survey encompassing 187 hospitals across 51 countries indicates that while in-hospital trauma care has received the most developmental priority, prehospital care is generally inadequate across the 3 stages of trauma management: prehospital, in-hospital, and rehabilitation.³ Currently, prehospital management of major trauma in China faces numerous challenges, including but not limited to: (1) A lack of unified standards for trauma assessment, management protocols, and technical application across regional prehospital care systems. (2) Insufficient dissemination and standardized application of modern trauma concepts such as damage control resuscitation and catastrophic hemorrhage control, as well as appropriate technologies like prehospital blood product transfusion, within the Chinese prehospital environment. (3) Information barriers and a lack of standardized information transfer and seamless linkage mechanisms between prehospital emergency services and in-hospital trauma centers.

To address these challenges, respond to the requirements of the "Healthy China 2030" plan, elevate the systematization and homogenization of prehospital major trauma care in China, and improve overall outcomes for severely injured patients, the Multiple Trauma Group of the Chinese Society of Traumatology initiated the development of this “Chinese expert consensus on the prehospital management of major trauma" (hereinafter referred to as “this consensus”). The effort involved collaboration with academic groups including the Youth Committee of the Chinese Society of Disaster Medicine, the Specialist Alliance for War Trauma Care of the Army Hospital System (Emergency Medicine), the Western China Trauma Alliance, the China County-level Hospital Emergency Alliance, and the Chongqing Emergency Medicine Consortium, engaging national experts from emergency medicine, trauma surgery, prehospital care, critical care medicine, and related fields.

2. Methods

2.1. Expert panel composition and conflict of interest management

An expert committee and a core working group were established. The expert committee comprised domestic experts from emergency medicine, traumatology, prehospital care, critical care medicine, and related fields, ensuring professional coverage and geographical representation. The core working group was responsible for literature retrieval, draft preparation, and project management. All participants were required to declare potential conflicts of interest. This consensus was registered on the “International Practice Guideline Registration for Transparency (PREPARE)" platform, registration number PREPARE-2025CN1598.

2.2. Core clinical questions and evidence retrieval

The core working group first identified clinical issues in prehospital major trauma care through literature review and solicitation of input from frontline clinicians and experts via email and online communication. Subsequently, an initial online expert panel discussion was held to deconstruct, merge, and prioritize the questions, ultimately distilling 14 key clinical questions (scene safety assessment, identification and pre-notification of major trauma, control of catastrophic external hemorrhage, airway management, breathing, circulation, neurological function, exposure and temperature control, geriatric trauma, splinting and patient movement, transport decision-making, prehospital-to-hospital handover, teamwork, and training). The core working group systematically searched databases including PubMed, Embase, Cochrane Library, Web of Science, China Biology Medicine, China National Knowledge Infrastructure, Wanfang Data, and VIP Information to collect evidence from systematic reviews, meta-analyses, randomized controlled trials (RCTs), cohort studies, case-control studies, observational studies, guidelines, and expert consensuses, covering the period from January 1, 2000 to December 31, 2025. The core working group meticulously reviewed and screened each piece of literature, considered evidence grading for the aforementioned clinical questions, and formulated preliminary recommendations.

2.3. Evidence evaluation and recommendation formulation

A modified Delphi method was employed, conducting multiple rounds of consultation with the expert panel via online questionnaires. Experts provided feedback on their level of agreement and suggested modifications for each recommendation. Statistical analysis of the results was performed to gradually converge on consensus, with finalization achieved through voting at a consensus meeting. On November 12, 2025, a full panel online vote was conducted. Experts voted on each recommendation using a 5-point scale: a. Fully agree, essential; b. Partially agree, with some reservations; c. Partially agree, with major reservations; d. Disagree, with some reservations; e. Completely disagree. Based on the voting results, recommendations receiving ≥80% votes for option “a" were designated as “Strongly Recommended”; those where the sum of votes for options “a" and “b" was ≥80% were designated as “Recommended”; those where the sum of votes for options “a", “b", and “c" was ≥80% were designated as “Suggested”; recommendations not meeting the threshold for “Suggested” were removed. This process yielded 16 final recommendations.

3. Consensus content

Clinical question 1: Scene safety assessment

Recommendation 1: Scene safety must be assessed and ensured during emergency response.

Strength of recommendation: Strongly Recommended

Rationale

This recommendation emphasizes the “step zero” in prehospital trauma care—scene safety assessment. The benefit of protecting rescuers from injury or death (i.e., achieving a 100% avoidance of becoming additional casualties) is absolute and substantial. Evidence primarily derives from authoritative international prehospital trauma care courses and guidelines (pre-hospital trauma life support (PHTLS))¹¹ and national occupational safety monitoring and policy reports (National Institute for Occupational Safety and Health Roadway Incident Safety).¹² The potential “risk” of performing scene safety assessment is only a minimal delay in initiating treatment, which is far outweighed by its benefits: ensuring the safety of rescuers, guaranteeing the continuation of the rescue mission, and preventing the consumption of additional medical resources. Its benefit-to-risk ratio is excellent. Therefore, the expert panel unanimously agreed that, although the evidence base is not primarily from RCTs, scene safety is an indispensable prerequisite and foundation for all subsequent life-support measures, given its critical importance and immense potential benefit. The core principle is that injured rescuers cannot aid patients and instead become new casualties, consuming already strained resources. Rescuers must adhere to the “me-my team-the patient and bystanders” safety principle, identifying and mitigating risks such as traffic, violence, environmental, and biological hazards (strictly adhering to “standard precautions”), and continuously reassess safety.

Clinical question 2: Identification and pre-notification of major trauma

Recommendation 2: It is recommended to rapidly identify major trauma based on physiological parameters, anatomical findings, mechanism of injury, special populations, and other high-risk factors.

Strength of recommendation: Strongly Recommended

Rationale

The primary task in prehospital major trauma care is the “rapid identification and activation” based on physiological, anatomical, mechanistic, special population, and other high-risk factors, using xABCDE (external hemorrhage control, airway, breathing, circulation, disability, exposure/environmental) as the main assessment framework.13, 14, 15, 16 Criteria for identifying major trauma (meeting anyone qualifies) include: (1) Physiological abnormalities, such as systolic blood pressure (SBP) <90 mmHg (or <110 mmHg for the elderly¹⁷); heart rate (beats/min) value >SBP (mmHg) value; respiratory rate <10 or >29 breaths/min; Glasgow coma scale (GCS) motor response (GCS-M score <6). (2) High-risk anatomical injuries, such as penetrating injuries to the head, neck, torso, and proximal extremities; suspected skull fracture; unstable, deformed, or suspected flail chest; 2 or more proximal long bone fractures; pelvic fracture; suspected spinal injury with new-onset motor or sensory deficit; active bleeding requiring a tourniquet or continuous direct pressure for control. (3) High-risk mechanisms of injury (e.g., fall from height >3 m in adults; passenger compartment deformation >30 cm; pedestrian/cyclist ejected, run over, or subjected to high-impact collision). (4) Special populations/high-risk factors: age ≥65 years, pregnancy ≥20 weeks, use of anticoagulant/antiplatelet medications, etc.

Clinical question 3: Control of catastrophic external hemorrhage

Recommendation 3: For patients with pulsatile or continuous bleeding from an extremity, clothing soaked with blood, pooling of bright red blood on the ground, or traumatic amputation, the application of a commercial tourniquet proximal to the wound is recommended. For bleeding from junctional areas (e.g., axilla, groin) or torso wounds, wound packing with sustained direct pressure is recommended; junctional tourniquets can be used if available.

Strength of recommendation: Strongly Recommended

Rationale

The core principle of this recommendation is to first identify and control catastrophic external hemorrhage during the X (exsanguinating external hemorrhage) phase of prehospital trauma care. The recommendation is primarily based on systematic reviews, clinical practice guidelines, and the United States (U.S.) Military's Tactical Combat Casualty Care (TCCC) guidelines.^18,19 Much of the experience in identifying and controlling prehospital life-threatening hemorrhage originates from military combat casualty care. For extremity hemorrhage, a standard commercial tourniquet is the first-choice, most effective tool. A retrospective cohort study in Los Angeles, U.S., demonstrated that prehospital tourniquet use was associated with increased survival and reduced transfusion requirements in patients with extremity vascular injuries.²⁰ For junctional areas, although modern combat experience suggests a role for junctional tourniquets in controlling junctional hemorrhage, clinical evidence remains limited.²¹ Currently, for civilian trauma, wound packing (potentially using hemostatic gauze) followed by at least 3 min of sustained direct pressure is still primarily recommended. When packing and pressure fail, junctional tourniquets can serve as an effective adjunct or alternative. Hemorrhage control efficacy should be assessed after tourniquet/packing application and repeatedly re-evaluated during transport, with the time of tourniquet application documented for subsequent in-hospital assessment and management.

Clinical question 4: Prehospital airway management

Recommendation 4: For patients in whom effective ventilation and oxygenation cannot be maintained through basic airway management techniques—including patient positioning, airway clearance, manual airway maneuvers, simple adjuncts (oropharyngeal/nasopharyngeal airways), and bag-valve-mask ventilation—advanced airway management methods such as supraglottic airways, endotracheal intubation, or cricothyroidotomy are recommended in the prehospital setting, based on equipment and skill availability. If the mechanism of injury or physical examination suggests potential cervical spine injury, simultaneous cervical spine protection is required.

Strength of recommendation: Strongly Recommended

Rationale

Prehospital airway management should follow a stepwise approach: begin with basic airway management (positioning, suction, manual maneuvers, simple airways, and bag-valve-mask ventilation). If basic techniques are ineffective, proceed to advanced airway management. In the prehospital environment, supraglottic airway (SGA) devices, due to their relative ease of use and high success rates, can be considered the primary advanced airway modality for initial management. Endotracheal intubation remains appropriate for experienced operators. Cricothyrotomy or needle cricothyroidotomy serves as the definitive rescue technique in “cannot intubate, cannot ventilate” scenarios. During all airway procedures, if cervical spine injury is suspected, manual in-line stabilization must be applied for cervical spine protection. Guidelines such as PHTLS, advanced trauma life support (ATLS), and the American Heart Association emphasize prioritizing basic airway management.^11,22, 23, 24, 25, 26 Multiple systematic reviews and large-scale registry studies comparing endotracheal intubation with SGA devices have concluded that there are no statistically significant differences between the 2 methods in terms of in-hospital mortality, survival rates, return of spontaneous circulation, or neurological recovery. These analyses suggest that SGA devices may offer practical advantages in the prehospital setting.27, 28, 29 Regarding cervical spine protection, although a recent national association of emergency medical services physicians (NAEMSP) review questions the benefit of routine spinal motion restriction,³⁰ mainstream guidelines like ATLS and PHTLS still uphold the principle of selective cervical spine protection when injury is suspected.^11,22,31

Clinical question 5: Assessment and maintenance of respiratory function

Recommendation 5: Assessment of respiratory function is recommended through observation of chest wall movement, respiratory rate and depth, skin color, and level of consciousness; auscultation of bilateral breath sounds; chest percussion; and monitoring of peripheral oxygen saturation (SpO₂). For patients with high-energy blunt or penetrating chest trauma who exhibit progressive dyspnea, hypotension, and absent breath sounds on the affected side, highly suggestive of tension pneumothorax, immediate needle thoracostomy decompression is recommended without awaiting radiographic confirmation.

Strength of recommendation: Strongly Recommended

Rationale

Respiratory assessment should be conducted systematically, with goal-directed oxygen therapy administered to maintain SpO₂ ≥ 94% (noting the potential for lag or inaccuracy in SpO₂ readings under conditions of shock and hypoperfusion). Tension pneumothorax represents a life-threatening emergency with a high rate of prehospital missed diagnosis. Once strongly suspected based on the clinical triad of progressive dyspnea, hypotension, and absent breath sounds on the affected side, immediate needle thoracostomy decompression is indicated without awaiting radiographic confirmation, to prevent delay in definitive management.

Multiple CT studies comparing chest wall thickness at different puncture sites suggest a potentially higher success rate at the mid-axillary line and emphasize the necessity of using a sufficiently long needle. The adult preference for the 5th intercostal space, mid-axillary line is primarily due to thinner chest wall thickness and potentially higher success rate compared to the 2nd intercostal space, midclavicular line, while also avoiding risk to the internal mammary vessels. If lateral chest access is restricted by patient position or equipment, the 2nd intercostal space, midclavicular line may still be used in adults, provided an extended-length needle (recommended ≥8 cm) is employed.^11,19 The 2nd intercostal space, midclavicular line remains the preferred site for children.²² Particular caution is required for left-sided needle decompression due to cardiac injury risk. Efficacy of decompression must be closely assessed post-procedure; failure may necessitate repositioning or transitioning to a more definitive decompression method (e.g., finger thoracostomy).³² Studies indicate high rates of both missed diagnosis³³ and false-positive needle decompression³⁴ for prehospital tension pneumothorax, highlighting the importance of accurate clinical judgment. Notably, failure rates for standard-length (5 cm) catheters at the 2nd intercostal space, midclavicular line can be high (potentially >40%) due to the inability to penetrate the thicker chest wall.35, 36, 37, 38, 39

Clinical question 6: Resuscitation, circulation management, and pelvic binder use

Recommendation 6: For patients with uncontrolled hemorrhage, a "permissive hypotension" strategy for fluid resuscitation is recommended, targeting a palpable radial pulse or an SBP of 90 mmHg. For patients with suspected traumatic brain injury (TBI) and impaired consciousness (GCS <9), to ensure cerebral perfusion, maintaining SBP ≥110 mmHg or mean arterial pressure ≥80 mmHg is suggested. Balanced crystalloid solutions are recommended for infusion, with normal saline as a secondary choice. For patients exhibiting signs of severe hemorrhagic shock (or predicted Class IV shock), transfusion of universal blood products should be prioritized when available.

Strength of recommendation: Strongly Recommended

Rationale

The core principle of this recommendation is the application of damage control resuscitation concepts in the prehospital setting, aiming to balance tissue perfusion against hemorrhage risk. Permissive hypotension: Rapidly restoring blood pressure to normal levels in patients with uncontrolled active hemorrhage may dislodge forming clots (“pop the clot”) and increase bleeding. Setting the resuscitation endpoint at a palpable radial pulse or SBP of 90 mmHg represents a balance between maintaining perfusion of critical organs and limiting hemorrhage.40, 41, 42 However, TBI is an exception. To ensure adequate cerebral perfusion pressure, a higher blood pressure target (SBP ≥110 mmHg or mean arterial pressure ≥80 mmHg) must be maintained for trauma patients with concomitant TBI.⁴³ Fluid choice: Balanced crystalloids are preferred over normal saline to avoid hyperchloremic metabolic acidosis, which can negatively impact coagulation.^44,45 For severe hemorrhagic shock, early transfusion of blood products is the most effective means to reverse shock and correct coagulopathy.^46,47

Recommendation 7: For trauma patients with suspected active severe hemorrhage or signs of hemorrhagic shock (e.g., pulse/heart rate >110 beats/min, or SBP <90 mmHg, or clinical judgment of significant hemorrhage despite normal blood pressure), intravenous administration of 1 g of tranexamic acid (TXA) as soon as possible within 3 h of injury is recommended, with the infusion lasting over 10 min.

Strength of recommendation: Strongly Recommended

Rationale

TXA is an antifibrinolytic agent that stabilizes formed clots and counteracts trauma-induced coagulopathy. It is particularly beneficial for patients with hemorrhage severe enough to cause hemodynamic instability. The clinical randomization of an antifibrinolytic in significant hemorrhage 2 trial definitively demonstrated that TXA administered within 3 h of injury significantly reduces all-cause mortality and death due to bleeding, without increasing thrombotic events.⁴⁸ Subgroup analyses showed greater benefit with earlier administration.⁴⁹ Based on this strong evidence, all major trauma guidelines, including the U.S. Military's Tactical Combat Casualty Care guidelines, ATLS, and the European guideline on trauma bleeding management, strongly recommend early TXA use.^22,50 The military application of TXA in trauma emergency resuscitation study also confirmed its effectiveness in the military setting.⁵¹ TXA reduces mortality from bleeding if given within 3 h of injury; administration beyond 3 h may be ineffective or harmful. Traditional shock definitions (SBP <90 mmHg) are often delayed. Young, healthy patients possess strong compensatory mechanisms and may maintain normal blood pressure until blood loss exceeds 30% (Class III shock). Therefore, TXA should not be withheld until hypotension develops. Early administration is indicated based on mechanism and clinical judgment of “significant hemorrhage risk".^22,50 The prehospital phase represents the golden window for the first loading dose. The standard regimen is a 1-g intravenous dose administered slowly (over at least 10 min) to avoid hypotension.

Recommendation 8: For patients with high-energy injury mechanisms, physical examination findings suggestive of pelvic fracture (e.g., bruising/tenderness over the pelvic region, leg length discrepancy, asymmetrical buttocks), or unexplained hemodynamic instability, pelvic fracture should be highly suspected, and immediate application of a commercial pelvic binder is recommended. The binder should be positioned at the level of the greater trochanters, with the patient's knees together and ankles internally rotated. Potential risks associated with pelvic binder use should be recognized.

Strength of recommendation: Strongly Recommended

Rationale

Unstable pelvic fractures can lead to life-threatening, difficult-to-control retroperitoneal hemorrhage. Substantial biomechanical evidence indicates pelvic binders effectively reduce unstable displacement of the pelvic ring.^52,53 Although large RCTs are lacking, numerous retrospective studies demonstrate that prehospital or early emergency department application of pelvic binders can stabilize hemodynamics and reduce transfusion requirements.⁵³ All authoritative guidelines include prehospital pelvic binder use as a standard procedure.^22,50,54 A study published by Injury in 2024, while not finding a significant impact on survival, still affirmed its role in fracture stabilization and hemorrhage control.⁵⁵

The primary functions of a pelvic binder: (1) To close the pelvic ring, reducing pelvic volume; (2) To exert tamponade pressure on bleeding points within the pelvis; (3) To stabilize fractures, alleviate pain, and prevent secondary injury. In accordance with the principle of “intervention upon high clinical suspicion”, specific indications for pelvic binder application include: (1) high-energy injury mechanism; (2) positive physical signs of pelvic fracture; (3) unexplained shock in a polytrauma patient. A standard pelvic binder should be positioned at the level of the greater trochanters (not the iliac crests), with the patient's knees brought together and ankles internally rotated before tightening.

Clinical question 7: Assessment of neurological dysfunction

Recommendation 9: In the prehospital environment, the alert, verbal, painful, unresponsive (AVPU) scale is recommended for rapid initial assessment of consciousness level. Following stabilization of airway, breathing, and circulation or during transport, a basic GCS score should be completed. Assessment should focus on pupillary light reflexes and motor function (particularly symmetry), with vigilance for dynamic deterioration in scores.

Strength of recommendation: Strongly Recommended

Rationale

Neurological assessment aims to promptly identify life-threatening TBI and guide goal-directed resuscitation. Hypotension (SBP <90 mmHg) and hypoxemia (SpO₂ < 90%) are primary contributors to secondary brain injury; these must be prioritized for exclusion or correction when assessing altered consciousness.^56,57 The prehospital scene is complex, and attempting a full GCS score during initial contact may interfere with core resuscitation. Therefore, a tiered assessment strategy is recommended: use the simple, rapid AVPU scale for initial screening during first contact; it correlates well with prognosis. A complete GCS assessment can be deferred to transport or when the patient is stabilized, serving as a common metric for prehospital-to-hospital handover.58, 59, 60, 61 When time pressure precludes a full GCS, priority should be given to recording the GCS-M and pupillary reaction. Evidence confirms that GCS-M combined with pupillary light reflex predicts TBI outcomes and intubation need as effectively as the full GCS.^62,63 Compared to a single score, a decline in GCS (≥2 points) or development of asymmetric pupils is often more clinically significant, potentially indicating expanding intracranial hematoma or impending herniation, warranting preparation for neurosurgical intervention.^64,65 Note that sedatives, analgesics, alcohol/drugs, hypothermia, and hypoperfusion can affect consciousness assessment; dynamic evaluation within the clinical context is advised.

Clinical question 8: Exposure and temperature management

Recommendation 10: During physical examination of major trauma patients in the prehospital setting, a restricted exposure strategy (exposing only the area being examined and covering it immediately afterward) is recommended, along with prompt removal of wet/cold clothing. A tiered combined approach to warming is recommended: begin with environmental rewarming; implement passive insulation; and initiate active warming with warmed fluid infusion as early as possible.

Strength of recommendation: Strongly Recommended

Rationale

Hypothermia (core temperature <35 °C) is a key component of the trauma lethal triad, significantly inhibiting thrombin activity and exacerbating platelet dysfunction, leading to uncontrollable hemorrhage. Studies indicate that for every 1 °C decrease in body temperature on hospital admission, transfusion requirements increase and mortality risk rises significantly in severely injured trauma patients.^66,67 While exposure is necessary for assessment, complete exposure in harsh prehospital environments leads to rapid heat loss that is difficult to reverse. Therefore, the modern concept emphasizes preventing heat loss takes precedence over full exposure. Implementing a segmental examination approach—exposing one area, examining it, then immediately covering it—or conducting thorough exposure only inside a warmed ambulance after establishing an active warming environment is recommended.⁶⁸ Removing wet clothing is fundamental to preventing conductive heat loss. Blankets or foil blankets alone only reduce passive heat loss; for patients already in hypothermic shock with impaired endogenous heat production, active rewarming using heat-generating devices (e.g., chemical heating blankets) is necessary. The head, with its rich vasculature and limited vasoconstriction capacity, is a major site of heat loss and should be covered first. The most readily implementable active warming measure prehospital is increasing the ambulance compartment temperature.⁶⁹ Infusion of large volumes of room-temperature fluids rapidly cools patients from within (approximately 0.25 °C drop per liter). Thus, European guidelines and NAEMSP position statements recommend warming intravenous fluids and blood products prior to infusion.^50,70

Clinical question 9: Management of geriatric trauma patients

Recommendation 11: For geriatric trauma patients, more proactive assessment and management measures should be adopted, fully considering their reduced physiological reserve, pre-existing conditions, and medication use.

Strength of recommendation: Strongly Recommended

Rationale

The elderly represent the fastest-growing demographic in China, with injury now the 5th leading cause of death in this population.^71,72 Due to declining physiological function (e.g., arterial stiffness, reduced pulmonary reserve), comorbidities (e.g., hypertension, cardiopulmonary disease), and medication effects (e.g., anticoagulants), elderly patients may be in “occult shock” even with “normal” vital signs. Evidence confirms that mortality begins to increase significantly in elderly patients when SBP falls below 110 mmHg.⁷³ Therefore, this consensus suggests defining SBP <110 mmHg as the threshold for hypotension in the elderly, warranting more proactive trauma activation and careful consideration of anticoagulant effects on bleeding risk. Because elderly patients often have baseline hypertension or take medications like beta-blockers or calcium channel blockers, their heart rate response to hypovolemia may be blunted (i.e., lack of tachycardia despite blood loss). This pseudonormality can lead to severe under-triage, causing patients to miss access to trauma resuscitation resources.74, 75, 76, 77 Ground-level falls are the most common injury mechanism in elderly trauma and a leading cause of fatal TBI and multiple fractures. Age-related cerebral atrophy makes bridging veins more susceptible to shear forces, so even minor trauma can cause hemorrhage; combined with widespread anticoagulant use (e.g., warfarin, rivaroxaban), this can lead to catastrophic intracranial or uncontrolled visceral bleeding.^78,79 Given these risks, this consensus recommends that for patients ≥65 years, even with normal range vital signs, the presence of high-risk factors (e.g., anticoagulant use with head trauma, polytrauma mechanism) should warrant upgraded triage and consideration of direct transport to a comprehensive trauma center.^80,81

Clinical question 10: Splinting and patient movement

Recommendation 12: For patients with high-energy blunt trauma accompanied by altered mental status, spinal tenderness, spinal deformity, or limb neurological deficit, spinal motion restriction (SMR) should be implemented. A rigid cervical collar of appropriate size is recommended. Long spine boards should be used solely as extrication devices; once the patient is transferred to the ambulance stretcher or a safe environment, the rigid spine board should be removed promptly. During patient movement, multi-person coordination is required to maintain axial alignment of the head-neck-torso. For patients requiring prolonged transport or immobilization, a vacuum mattress is recommended as the primary transport device.

Strength of recommendation: Strongly Recommended

Rationale

The goal of SMR is to prevent secondary neurological injury by minimizing unnecessary spinal movement, not to achieve absolute immobility (which is impossible). SMR is not indicated for all trauma patients but is reserved for high-risk individuals with specific criteria, including high-energy injury mechanism, altered level of consciousness, spinal pain/tenderness, neurological deficit, or spinal anatomical deformity. Historically, long spine boards were standard transport tools. However, substantial high-level evidence now shows that prolonged immobilization on rigid spine boards leads to pressure injuries, significant pain, restricted ventilation, and imaging artifacts.^82,83 A joint position statement from NAEMSP and the American College of Surgeons Committee on Trauma clearly states: spine boards are primarily for “extrication” (moving the patient from the incident scene); once the patient is in a safe environment (e.g., inside the ambulance), the board should be removed as soon as possible.^22,30 PHTLS, ATLS, and joint position statements from American College of Surgeons Committee on Trauma, American College of Emergency Physicians, and NAEMSP^11,22,82,83 collectively establish the paradigm shift from immobilization to selective spinal motion restriction and define SMR indications and methods. For penetrating neck or torso trauma, the incidence of spinal instability is low (<1%). Multiple studies indicate that enforced SMR in these patients is not only unhelpful but harmful, as procedural delays definitive hemorrhage control surgery, and cervical collars may mask expanding neck hematomas or impede airway management. Therefore, unless the patient has a clear neurological deficit (e.g., paralysis), SMR should not delay transport.^31,84 Vacuum mattresses, which conform perfectly to the body's spinal contours providing uniform supportive pressure, are proven to offer superior immobilization compared to spine boards while significantly enhancing patient comfort and reducing complications, making them the internationally recognized optimal transport device.⁸⁵ A scoop stretcher serves as the best tool for minimizing spinal torsion during lifting, recommended for transferring the patient from the ground to the transport stretcher.

Clinical question 11: Destination hospital and mode of transport

Recommendation 13: Major trauma patients should be transported to the nearest appropriate trauma center with definitive care capabilities. For patients in remote areas or with excessively long ground transport times, helicopter emergency medical services (HEMS) may be considered when available.

Strength of recommendation: Strongly Recommended

Rationale

The core of this recommendation is the right patient, to the right hospital, at the right time. For critically injured patients with physiological abnormalities or severe anatomical injuries (e.g., penetrating trauma, flail chest, amputation), bypassing facilities without comprehensive trauma capabilities and proceeding directly to the highest-level trauma center in the region is mandatory. Diversion to the nearest hospital for stabilization should only be considered if the airway cannot be secured or there is uncontrolled hemorrhagic shock with prohibitively long transport times. The traditional closest facility principle has been modified for major trauma. Numerous retrospective cohort studies confirm that patients with an injury severity score >15 have a 25% lower mortality rate when transported directly to a Level I trauma center compared to a non-trauma center.⁸⁶ For patients meeting physiological (e.g., GCS <14, SBP <90 mmHg) or anatomical (e.g., 2 or more long bone fractures, pelvic fracture, spinal cord injury) criteria, a time for capability strategy is justified—sacrificing some additional transport time to access a higher level of definitive care.⁸⁷

HEMS can overcome geographical barriers and shorten transport times, representing an important option for critically injured patients in remote areas or with severe ground traffic congestion. However, HEMS activation requires standardized protocols integrating medical indications, weather, landing zone availability, and cost-effectiveness. For urban trauma, if a Level I/II trauma center is reachable within an acceptable timeframe (typically <45 min), ground transport often offers faster launch and provides continuous space for interventions like cardiopulmonary resuscitation. Recent Cochrane reviews and studies published by Journal of the American Medical Association suggest survival benefits from HEMS are primarily attributable to the advanced care provided during flight (e.g., prehospital blood transfusion, advanced airway management) and the speed advantage over long distances.^88,89 If the total activation + flight + loading time for a helicopter exceeds the estimated ground transport time, HEMS should not be used. Domestic expert consensus suggests 45–60 min as a threshold for considering air vs. ground transport.⁹⁰

Clinical question 12: Prehospital-to-hospital handover

Recommendation 14: To ensure accurate, complete, and efficient handover, the use of a standardized prehospital-to-hospital information handover tool is recommended. The age, time of incident, mechanism of injury, injuries found, signs (vital signs and trends), treatments given (ATMIST) model is recommended as the standard format for both verbal and written handover.

Strength of recommendation: Strongly Recommended

Rationale

The prehospital-to-hospital handover is a critical node within the “golden hour” of major trauma care; its quality directly impacts subsequent diagnosis, treatment, and team response efficiency. Studies indicate that unstructured patient handover may result in the omission of approximately 1/3 of critical clinical information.⁹¹ ATMIST is currently the most widely used trauma handover model internationally. By structuring information into 6 fixed elements (age, time, mechanism, injuries, signs, treatments), it creates a logical framework ensuring the receiving team comprehensively understands the patient's situation in a short time. In the often chaotic environment of the emergency resuscitation bay, multiple trauma observational studies and quality improvement projects confirm that implementing a hands-off strategy—where, for approximately 30 sec during the handover, all personnel except those performing ongoing cardiopulmonary resuscitation pause patient movement, connecting lines, etc., maintain silence, and focus visually on the person reporting—significantly improves information reception accuracy and team situational awareness.^92,93 The in-hospital receiver should have a designated handover lead who listens, acknowledges, and repeats back key information for closed-loop communication. In a Scotland-wide study, the ATMIST model was deemed the most practical handover format for its clarity and comprehensiveness.⁹⁴ A before-after study showed a significant increase in handover information completeness after implementing ATMIST record cards.^95,96 A prospective field test conducted across 11 hospitals in Prague demonstrated that a standardized prehospital-to-hospital information handover tool based on the ATMIST model effectively ensured the accurate transmission of on-scene information to receiving facilities.⁹⁷ Although recent research suggests that the initial mechanism, injuries, signs, treatment – age, medical history, background, other information (IMIST-AMBO) tool offers an information structure more aligned with emergency physicians' prioritization of critical clinical data, demonstrating superior performance in structural organization, procedural flow, time efficiency, and the limitation of non-essential information transmission,⁹⁸ and despite its endorsement in the 11th edition of the ATLS manual,³¹ the present consensus continues to recommend the ATMIST model as the standardized handover tool. This recommendation is based on the current widespread adoption of ATMIST within existing prehospital training programs in China, aiming to ensure continuity in information transfer and to avoid the cognitive load associated with transitioning to a new model.

Clinical question 13: Teamwork

Recommendation 15: To ensure efficient management, on-scene teams should operate under unified command, with clear role division and closed-loop communication.

Strength of recommendation: Strongly Recommended

Rationale

Trauma scenes are often high-pressure environments characterized by incomplete information, noise, and multi-agency coordination. Unified command prevents conflicting instructions and facilitates critical decision-making. Clear role division assigns specific tasks (e.g., airway/breathing, circulation/hemorrhage control, monitoring/recording) to team members. Closed-loop communication, through a standardized order–verbal confirmation–completion feedback process, significantly enhances task completion rates and speed. Studies show that establishing a prehospital teamwork system centered on unified command, clear roles, and closed-loop communication improves the accuracy and speed of task execution, thereby enhancing overall process efficiency.^99,100 Major incident analyses identify a single command structure and clear task allocation as prerequisites for rapid decision-making.¹⁰¹ The European Resuscitation Council Education and Implementation Guidelines note that 70% of medical errors stem from communication failures rather than technical mistakes. Structured simulation, inter-professional drills, and video debriefing can significantly improve team coordination and emergency response capabilities.¹⁰² Emergency teams should integrate non-technical skills like leadership, communication, and teamwork into routine training and video review sessions, developing a replicable, evaluable collaborative paradigm.

Clinical question 14: Systematic training

Recommendation 16: It is recommended to establish a systematic, competency-based training system for prehospital major trauma care, grounded in the xABCDE protocol. This system should encompass pre-service entry training, periodic in-service refresher courses, and specialized training targeting identified weaknesses and high-risk, low-frequency scenarios.

Strength of recommendation: Strongly Recommended

Rationale

Establishing a systematic, standardized training system for prehospital major trauma care is crucial for maintaining and enhancing rescuers' core clinical competencies, confidence, and communication skills.¹⁰³ Non-systematic, fragmented training models are ineffective for sustaining the clinical capability to manage complex trauma, especially for high-risk, low-frequency procedures like difficult airway management or needle thoracostomy, where skill decay is common. A systematic review and meta-analysis noted that trauma team training implementation can accelerate the performance of key interventions by prehospital personnel.¹⁰⁴ Regarding teaching methodology, high-fidelity simulation is recognized as a key modality, allowing learners to effectively integrate knowledge, skills, and teamwork under pressure. High-fidelity simulation significantly improves team communication, leadership, and task allocation, facilitating the transfer of learning to real clinical settings.^105,106 In the context of rapid artificial intelligence development, some researchers are exploring integrating artificial intelligence application scenarios into high-fidelity simulation training to enhance medical personnel's prehospital trauma management capabilities.¹⁰⁷ To ensure training effectiveness, rigorous skill assessment and certification mechanisms must be established, achieving homogenized training quality and enabling continuous improvement. Training content must be centered on the latest evidence-based clinical guidelines to ensure scientific rigor and currency, empowering emergency teams to deliver standardized, efficient, and safe prehospital major trauma care in complex and variable field environments.

4. Summary and statement

This consensus is an academic article developed based on the best currently available evidence and expert opinions, and is intended to serve as a reference for clinical decision-making. It is not a substitute for individualized clinical judgment and should not serve as a legal basis for handling medical disputes. The vitality of a consensus lies in its implementation and iteration. We encourage local emergency medical services and trauma centers to develop standardized operating procedures tailored to their specific contexts based on this consensus and to conduct systematic training and quality control. In the future, as more high-quality, localized evidence emerges, this consensus will undergo periodic revision and updates to maintain its scientific validity and relevance.

CRediT authorship contribution statement

Yang Li: Writing – original draft, Writing – review & editing. Liangjun Lang: Writing – original draft. Jiliang Zhang: Conceptualization, Writing – original draft. Quanwei Bao: Data curation. Rui Long: Formal analysis. Zeng Huang: Data curation. Zilong Li: Project administration. Lianyang Zhang: Conceptualization, Project administration.

Ethical statement

Not applicable.

Funding

This work was supported by the Science and Technology Project of the Chongqing Municipal Education Commission (Grant No. KJZD-M202512803), and the Sprint Project of the Chongqing Science and Health Joint Project (Grant No. 2025CCXM001).

Declaration of competing interest

All experts involved in developing this consensus have completed conflict of interest declarations. No significant conflicts of interest relevant to the content of this consensus were identified.

Appendix section

Consensus Groups: Trauma Emergency and Multiple Trauma Group of the Trauma Society of the Chinese Medical Association (CMA); the Youth Group of the Disaster Medicine Society of the CMA; Combat and Trauma Care Specialty Alliance of Army Hospitals; Western China Trauma Alliance; China County-level Hospital Emergency Alliance; Chongqing Emergency Medicine Consortium.

Consensus Writing Committee (Sorted alphabetically by surname)

Shanmu Ai (Chongqing Emergency Medical Center), Quanwei Bao (Daping Hospital, Army Medical University), Ke Cao (Yuyao Emergency Center), Chensong Chen (Xiangshan First People's Hospital), Fang Chen (Guilin 120 Command Center), Guofeng Chen (The Affiliated Yangming Hospital of Ningbo University), Haiming Chen (The First Affiliated Hospital of Nanchang University), Yunfei Chi (Chinese PLA General Hospital), Junru Dai (Sir Run Run Shaw Hospital, Zhejiang University School of Medicine), Xingbo Dang (Shaanxi Provincial People's Hospital), Weiwei Ding (General Hospital of Eastern Theater Command), Jianjiang Fang (Ningbo Medical Center Lihuili Hospital), Yong Fu (The Second Affiliated Hospital of University of South China), Wei Gao (Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology), Dingxiu He (Deyang People's Hospital), Wubing He (Fujian Provincial Hospital), Hequn He (The First Affiliated Hospital of Ningbo University), Ciqun Hu (Yuyao Emergency Center), Hongqiang Hu (Hospital of the 73rd Group Army of the PLA), Peiyang Hu (Tiantai People's Hospital), Jian Huang (Chongqing Liangjiang New Area People's Hospital), Jie Huang (Hunan Provincial People's Hospital), Junhua Huang (Zhoushan Hospital), Ping Huang (The Affiliated Yangming Hospital of Ningbo University), Wei Huang (Peking University People's Hospital), Zeng Huang (The Affiliated Yangming Hospital of Ningbo University), Jinmeng Huo (Guilin People's Hospital), Ping Jin (The Affiliated Yangming Hospital of Ningbo University), Lingjun Kong (Chengdu Pidu District People's Hospital), Liangjun Lang (The Affiliated Yangming Hospital of Ningbo University), Chao Lan (The First Affiliated Hospital of Zhengzhou University), Changlu Li (Ningbo Emergency Center), He Li (The Second Affiliated Hospital of Anhui Medical University), Jiayu Li (People's Hospital of Guangxi Zhuang Autonomous Region), Junjie Li (Xijing Hospital, Air Force Medical University), Lianxin Li (Shandong Provincial Hospital), Songtao Li (The 924th Hospital of PLA Joint Logistic Support Force), Xiaobao Li (Leiyang People's Hospital), Xiaoxue Li (Chinese PLA General Hospital) , Wei Li (Hospital of the 71st Group Army of the PLA), Yang Li (Daping Hospital, Army Medical University), Yunming Li (General Hospital of Western Theater Command), Zhengzhao Li (The Affiliated Wuming Hospital of Guangxi Medical University), Zilong Li (The Affiliated Yangming Hospital of Ningbo University), Jian Liang (The Affiliated DaZu Hospital of Chongqing Medical University), Qiqing Lin (Affiliated Hospital of Youjiang Medical University for Nationalities), Qiaoqiao Ling (Taizhou Emergency Center), Zhian Ling (The Second Affiliated Hospital of Guangxi Medical University), Cheng Liu (Nanhua Hospital, University of South China), Guangming Liu (Chengdu Pidu District People's Hospital), Junting Liu (The First Affiliated Hospital of Guangxi Medical University), Guie Liu (Daping Hospital, Army Medical University), Rui Long (Daping Hospital, Army Medical University), Xinbo Lou (Yuyao Emergency Center), Li Lu (University Town Hospital of Chongqing Medical University), Xiaozhen Lu (Ningbo No.2 Hospital), Chunting Luo (Nanning Emergency Medical Center), Bin Ma (Hospital of the 82nd Group Army of the PLA), Jianfei Ma (Daping Hospital, Army Medical University), Longyang Ma (Shaanxi Provincial People's Hospital), Qiang Ma (Affiliated Hospital of Qinghai University), Xinkui Ma (Jianyang People's Hospital), Yu Meng (The First Affiliated Hospital of Zhengzhou University), Zhenchao Ni (The Affiliated Yangming Hospital of Ningbo University), Chunqiu Pan (Nanfang Hospital, Southern Medical University), Sijun Pan (Anji People's Hospital), Changbiao Peng (Zhujiang Hospital, Southern Medical University), Na Peng (General Hospital of Southern Theater Command), Hua Qiang (Yinchuan First People's Hospital), Eryue Qiu (Zhuzhou Hospital Affiliated to Xiangya School of Medicine, Central South University), Yi Shan (The Sixth Medical Center of Chinese PLA General Hospital), Chuanwen Shen (Chongqing Qianjiang Central Hospital), Yin Shen (Guangxi Orthopaedic Hospital), Qingyun Shi (Yuyao Emergency Center), Qiaoling Song (Daping Hospital, Army Medical University), Wenwu Sun (Daping Hospital, Army Medical University), Dan Tan (The Second Affiliated Hospital, Army Medical University), Huamin Tang (Guangxi International Zhuang Medicine Hospital), Shi Tang (The 955th Hospital of PLA), Pan Tian (Hospital of the 82nd Group Army of the PLA), Shaoqiang Tian (Shenyang First People's Hospital), Dong Wan (The First Affiliated Hospital of Chongqing Medical University), Juan Wang (Shenzhen Emergency Center), Hailong Wang (Weinan Central Hospital), Jianping Wang (Gansu Provincial Hospital), Nan Wang (The First Affiliated Hospital of Zhengzhou University), Qingwei Wang (Hangzhou Xiaoshan Traditional Chinese Medicine Hospital), Sai Wang (The 953 Hospital of the PLA Army), Qiaoshu Wei (Daping Hospital, Army Medical University), Guoping Wu (Sansha People's Hospital), Fei Xia (The Affiliated Hospital of Guizhou Medical University), Lifeng Xiao (Cancer Hospital of Shantou University Medical College), Wei Xiao (Sir Run Run Shaw Hospital, Zhejiang University School of Medicine), Baoling Xu (The Second Affiliated Hospital of Guilin Medical University), Liming Xu (Zhejiang Provincial People's Hospital), Peng Yang (The First Affiliated Hospital of Soochow University), Wenren Yang (Nanhua Hospital, University of South China), Le Yao (Beihai People's Hospital), Feng Yi (Yueyang Central Hospital), Chaoping Yu (Eastern Theater Air Force Hospital), Xiaojun Yu (Wuzhou Red Cross Hospital), Haifang Yu (West China Hospital, Sichuan University), Yigang Yu (The 909th Hospital of Joint Logistic Support Force), Anyong Yu (Affiliated Hospital of Zunyi Medical University), Defeng Zhang (The Affiliated Yangming Hospital of Ningbo University), Feng Zhang (Hospital Affiliated to Army NCOS School), Jiliang Zhang (Guilin People's Hospital), Weitao Zhang (Yan'an People's Hospital), Xingwen Zhang (Hunan Provincial People's Hospital), Yan Zhang (The First Affiliated Hospital of Zhengzhou University), Zhongrong Zhang (The 958th Hospital of the PLA Army), Ke Zhang (Gansu Provincial Hospital), Lianyang Zhang (Daping Hospital, Army Medical University), Pengdong Zhang (Tangshan Central Hospital), Qinpeng Zhao (Xi'an Emergency Center), Xiaogang Zhao (The Second Affiliated Hospital, Zhejiang University School of Medicine), Yiming Zhao (Sir Run Run Shaw Hospital, Zhejiang University School of Medicine), Hui Zheng (Hangzhou Ninth People's Hospital), Jianchun Zong (The Second Affiliated Hospital of Chongqing Medical University), Yi Zhu (Daping Hospital, Army Medical University).