Should the 'C' in 'ABCDE' be altered to reflect the trend towards hypotensive resuscitation?

Background: Fluid resuscitation of trauma victims currently differs, depending on whether the Advanced Trauma Life Support (ATLS), Prehospital Trauma Life Support (PHTLS) or Battlefield Advanced Trauma Life Support (BATLS) algorithm is utilised. Resuscitation protocol depends on the situation of the patient before definitive surgical control of the haemorrhage can be achieved, that is, in the prehospital phase (the urban, rural or battlefield setting) or in the emergency room. The principle difference is between hypotensive (PHTLS and BATLS, in the prehospital phase) and normotensive (ATLS, in the emergency room) resuscitation. The aim of this review was to determine if there is sufficient evidence to consider altering the ATLS resuscitation algorithm to a hypotensive model prior to definitive surgical control of haemorrhage. Method: A literature review was conducted of the experimental and clinical evidence for hypotensive resuscitation. Results: Uncontrolled haemorrhage models are too severe. They do not realistically mimic - and their results cannot easily be extrapolated into - clinical scenarios. One important clinical trial, inspired by these experimental models, has rightly influenced resuscitation of shocked prehospital patients towards a 'scoop and run' approach and permissive hypotension but it is specific to patients with penetrating trauma alone. Conclusion: There is insufficient evidence to alter the current ATLS algorithm in the emergency room in favour of hypotensive resuscitation. The future of resuscitation is considered.