Abstract
<jats:p>Background. The global standard for primary assessment of trauma patients has undergone fundamental changes under the influence of evidence-based military medicine. The xABCDE approach (“hemorrhage first”) based on the MARCH and TCCC protocols, has been officially integrated into the 11th edition of the ATLS guidelines (2025). In Ukraine, the full-scale war has effectively blurred the distinction between military and civilian trauma, as civilians frequently sustain blast and shrapnel injuries. Despite this, many Ukrainian civilian protocols still adhere to the outdated ABCDE model in which the airway is the first priority, creating a risk of preventable mortality from bleeding. This study aims to conduct a comparative analysis of civilian ABCDE and the modern xABCDE schemes, taking into account international experience and the realities of the war in Ukraine, to develop recommendations for the unification of protocols and their implementation in the simulation-based training system. Materials and methods. This study employed a systematic literature review methodology. The search encompassed databases such as Scopus, Web of Science, MEDLINE (PubMed), The Cochrane Library, and Google Scholar for publications up to 2025. Additionally, the analysis included official guidelines from the American College of Surgeons, American Heart Association, Resuscitation Council UK, and the Ministry of Health of Ukraine. Inclusion criteria focused on systematic reviews, meta-analyses, and original clinical trials regarding trauma algorithm modifications. Results. The analysis confirmed a global paradigm shift toward the xABCDE (eXsanguinating hemorrhage first) sequence. Consequently, the study identified that under modern conflicts, over 50 % of preventable trauma deaths result from massive external bleeding, which kills faster than airway obstruction. Moreover, data from Ukraine demonstrated that civilian injury patterns following missile strikes mirror combat trauma, characterized by a predominance of extremity injuries. As a result, the traditional A-B-C prioritization leads to fatal delays in life-saving maneuvers like tourniquet application. The critical appraisal of the Ukrainian regulatory framework revealed a significant gap: while military and first-aid rules prioritize hemorrhage control, the primary civilian “Polytrauma” protocol (Order No. 34) remains airway-oriented. Furthermore, the study established that simulation-based training provides the most effective methodology for deconstructing ingrained medical habits. For example, the proposed modular simulation curriculum allows healthcare providers to automate the “x” step under high-stress conditions, which can significantly reduce the time to stop bleeding. In summary, the transition to xABCDE is not only a medical, but also a strategic step to reduce the mortality rate in trauma in Ukraine. Conclusions. The study demonstrated the urgent need to standardize the xABCDE algorithm as the single primary assessment protocol in Ukraine for all trauma categories. Moreover, simulation training serves as the crucial tool for the rapid implementation of these changes.</jats:p>