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Injury is a major cause of death and disability globally, with the highest burden in low‐ and middle‐income countries (LMICs). Strengthening the organization and planning for trauma care (care of the injured) can improve care and lower mortality. In 2004, the International Association for Trauma Surgery and Intensive Care (IATSIC) and the World Health Organization (WHO) co‐published the Guidelines for Essential Trauma Care ( EsTC ). The goals of the Guidelines for EsTC were to promote affordable and achievable standards for trauma care resources that could realistically be achievable at health care facilities anywhere in the world, even in the lowest‐income settings. By so doing, IATSIC and WHO hoped to strengthen trauma care services globally, especially in LMICs. Since its publication in 2004, the Guidelines for EsTC have been extensively cited. More importantly, there have been documented, published examples of implementation of the Guidelines in 48 countries worldwide, spanning all economic levels from low‐income to high‐income countries.

The current publication represents the first update and revision of the Guidelines for EsTC . As with the first edition, the current edition contains resource tables listing human resources (skills, training, staffing) and physical resources (equipment and supplies) that should be available at varying health care facilities in all countries, ranging from clinics to first‐level hospitals to second‐level hospitals to tertiary hospitals. These resource tables cover the breadth of trauma care, including initial management and resuscitation to definitive care of most major injuries. As with the original version, these resource tables are meant to be flexible to allow adjustments as needed to tailor them based on local health care system resources and capabilities. The Guidelines focus on fixed facilities, as other publications address prehospital care.

This update was developed by IATSIC, with input and advice from WHO staff members and with use of several WHO publications on emergency care, surgical care, resources for humanitarian care, essential medicines, among others. It was also developed with input from the Trauma Care Resource Consensus Group, convened specifically for this revision and consisting of 36 experts from all continents and from a wide breadth of professional backgrounds. The revision reflects the solid trauma care principles found in other IATSIC resources, such as its National Trauma Management Course and its Definitive Surgical Trauma Care Course. The target audience for these Guidelines includes: ministry of health planners, hospital administrators (including nursing service directors and department/medical service directors), and trauma care clinicians including surgeons of all sub‐specialties, emergency physicians, anesthetists, nurses, and other professionals who care for the injured. It is intended that planners and administrators will use the Guidelines in developing trauma services and allocating resources for these services. It is also intended that clinicians will use these Guidelines as a minimum standard to identify and demonstrate to planners and administrators key gaps that need to be addressed.

The Guidelines conclude with consideration of key administrative functions that should be active at health care facilities to assist with achieving the resource requirements and to assure the quality of trauma care. These include: quality improvement programs, trauma registries, use of continuing professional development courses, triage systems, trauma teams, tools (e.g., checklists), and trauma care protocols.

Finally, it is interesting to note how the changes in resource designations since the 2004 version reflect improvements in trauma care capabilities globally. The expert consensus process used to develop the Guidelines in both 2004 and currently provides a snapshot of what global experts consider feasible to promote, across diverse settings, even in the most resource‐constrained circumstances. Due in part to increased attention to trauma care, improved economic standards in many countries, and lower costs for some items of technology, several critical items that were not recommended or were recommended only at tertiary levels previously, are now recommended to be much more widely applicable at many other levels of the health care system. These include (among others) pulse oximetry, mechanical ventilation, ultrasonography for diagnosis of intra‐abdominal bleeding, and laboratory facilities for measurement of electrolytes and arterial blood gases. The developers of the current version of the Guidelines for EsTC hope and intend that this version will be used as extensively as the 2004 version and will achieve similar improvements in trauma care capabilities globally.

Injury is one of the leading causes of death and disability globally. Each year, it accounts for 4.4 million deaths (8% of all deaths globally) [] and 268 million disability adjusted life years (DALYs) lost (10% of all DALYs globally) [, ]. The vast majority (over 80%) of all injury related deaths occur in low‐ and middle‐income countries (LMICs). Rates of injury‐related death are highest in low‐income countries (78/100,000/year) and in lower‐middle‐income countries (58) than in upper‐middle‐income (51) and high‐income countries (53) [, , , ].

Part of the reason for the higher injury death in LMICs is more unsafe conditions, such as higher rates of road traffic crashes. Part of the reason is because of higher case‐fatality rates in LMICs once someone is injured. Several studies have documented such increased rates. For example, a study from India showed mortality for hospitalized patients to be eight times higher than for hospitalized patients in the USA (23.2% vs. 2.8%), despite the fact that the groups had similar degrees of injury (both with median Injury Severity Score—ISS—of 9) []. Similarly, looking at both prehospital and hospitalized patients with severe injuries (ISS of 9 or more), mortality rates rose from 35% in a high‐income country to 55% in a middle‐income country to 63% in a low‐income country []. Eliminating these inequalities in case‐fatality rates could save one million lives per year [].

Contributing to the above discrepancies in case‐fatality rates for injured patients are limitations in resources for trauma care (care of the injured) in LMICs. These include limitations of human resources (staffing, training) and physical resources (equipment, supplies) for trauma care. Studies from numerous LMICs have documented shortcomings in the availability of many trauma care services and the resources needed to provide them. These include high‐cost items (e.g., computerized tomography—CT scans). But, there are also shortages in many lower‐cost items, such as airway equipment and IV fluids, which are often absent not because of their cost but because of shortcomings in organization and planning [, , , , , ]. It is important to emphasize that much of trauma care is very affordable and cost‐effective. A range of trauma care services in several LMIC hospitals has been estimated to cost $87–$302 per DALY averted. This compares very favorably to several widely used public health measures such as oral rehydration solution (US$1000 per DALY averted) and antiretroviral therapy for HIV/AIDS (US$900 per DALY averted) [, , ].

In addition to human and physical resources, there is a dearth of administrative mechanisms to assure the quality of trauma care at most LMIC hospitals, including quality improvement programs, trauma registries, trauma teams with pre‐assigned roles, and transfer protocols (among others). As with the physical resources noted above, most of these mechanisms are very low‐cost. Addressing such deficiencies has been the goal of several World Health Assembly resolutions on trauma care, and on surgical care and emergency care more generally. These resolutions have also encouraged the development of minimum standards for trauma and other emergency care services and the resources needed to provide them [, , , ].

In order to promote improved organization and planning for trauma care services globally, the International Association for Trauma Surgery and Intensive Care (IATSIC) and the World Health Organization (WHO) co‐published the Guidelines for Essential Trauma Care ( EsTC ) in 2004 []. The goal of the Guidelines for EsTC was to better define what essential trauma treatment (care) services should realistically be made available to almost every injured person worldwide. It then defined the human resources (training and staffing) and physical resources (supplies and equipment) necessary to provide these essential trauma care services, even in the lowest income settings. It created a flexible matrix of over 200 elements of human and physical resources that was intended to serve as a template to be used as a guide for those planning trauma care services for their countries or areas, including both clinicians and administrators. The recommendations of the Guidelines were intended to be practical and to be realistically achievable within the confines of tight health care budgets in most LMICs. The Guidelines addressed care for a range of injuries, including those arising from blunt trauma (e.g., road traffic crashes, falls), penetrating trauma (e.g., gunshot wounds, stab wounds), and burns. Many of the resources that it addresses are also important for the treatment of a wide range of other emergency conditions, such as those for treatment of obstructed airways, hypoxia, and shock.

The 2004 Guidelines for EsTC have been widely implemented around the world. In 2016, a systematic review was published on this implementation [] (covering 2004–May 2015). In preparation for this current revision of the Guidelines , the systematic review was updated (covering June 2015 to April 2025), with the results contained herein. Altogether (2004–2025), 117 separate instances of implementation of the Guidelines for EsTC have been published, covering 48 countries across the economic spectrum (from low‐income to high‐income), in addition to regional and global implementation [] (Appendix ). The majority of these have been needs assessments ( n = 61) in which the Guidelines for EsTC were used as a template against which to compare the human and physical resources available at clinics and hospitals in given area or country.

In two countries (Ghana and Vietnam), these needs assessments served as stimuli to promote improvements, which were documented by subsequent studies [, , ]. In Vietnam, the Hanoi Health Department runs a network of clinics (commune health stations), first‐level, and second‐level hospitals. Clinicians working in the health department used the Guidelines for EsTC to evaluate the availability of 12 items of human and physical resources at the network of facilities. This identified deficiencies in several low‐cost resources. Advocacy by the clinicians helped to bring these deficiencies to the attention of health department leaders. As most of the items were low‐cost, addressing them was primarily a matter of attention to detail in planning, rather than cost. Repeat surveys over the next several years documented improvements, with nine of 12 items (e.g., basic airway equipment) improving in availability at the clinics and almost all of the 12 items improving at both hospital levels [, ]. A similar study in Ghana used the Guidelines to document changes in trauma care capacity over a 10‐year period, during which there had been several initiatives that encompassed trauma care nationwide. Advocacy related to the findings of the essential trauma care survey was one of these. The essential trauma care surveys also provided an internationally‐recognized metric to use to monitor changes. Changes over time included improvements in most (but not all) resources evaluated. For example, oxygen availability increased from under 50% to nearly 100% at second‐level hospitals [].

Other types of implementation events have included stakeholder endorsements ( n = 25), in which groups (especially country professional societies) have formally endorsed the Guidelines and called on their governments to utilize them (e.g., the Academy of Traumatology (India) and the Ecuadorian Trauma Society). Smaller numbers of instances of implementation have included: use in educational interventions ( n = 14) and policy development ( n = 14). Examples of educational interventions include that the Guidelines were incorporated into educational modules for humanitarian aid workers in Burkina Faso and Sierra Leone and for emergency nurses in Sri Lanka. An example of policy implementation includes that the Guidelines were cited and utilized in the development of regulations on emergency care in Mexico. It should be noted that the above implementation events are only those that were found by a literature search. There are likely many more implementation events that were not published. Finally, the low number of episodes of incorporation into policy indicates a barrier to overcome in future efforts to implement the Guidelines .

The Guidelines for EsTC have now been updated in 2026. A working group of IATSIC members, with input from WHO staff, made preliminary updates to the 2004 resource grids, including changing designations of resources as to whether they were core, extended, or not applicable at different levels of the health care system (more in Section ) and adding new resources that were not covered in the 2004 edition. These were then reviewed and commented on by the Trauma Care Resource Consensus Group which consisted of 35 members from all continents and from countries at all economic levels. This group came from a wide variety of professional backgrounds involved in care of the injured, including: anesthesia, critical care, emergency medicine, family medicine/general doctors (especially those working at first level hospitals), neurosurgery, nursing (including critical care nursing and trauma nursing), pediatric surgery, rehabilitation, and trauma surgery (both general surgery and orthopedics). The consensus group included members of IATSIC and members of several of the professional societies that are members of WHO's Global Alliance for Care of the Injured (GACI): including African Federation of Emergency Medicine, AO Alliance, G4 Alliance, International Committee of the Red Cross, International Federation of Emergency Medicine, International Federation of Red Cross and Red Crescent Societies, Médecins Sans Frontières, Panamerican Trauma Society, Society of Trauma Nurses, and the World Federation of Critical Care Nurses.

The preliminary changes made by the IATSIC working group were amended as needed based on input from the consensus group. The resource assignments took into account and were harmonized as needed with several WHO resources, including the Model List of Essential Medicines [], high‐priority health services for humanitarian response (H3 package) [], essential resources for emergency and critical care (ERECC), Universal Health Coverage (UHC) Service Package Delivery and Implementation (SPDI) Platform [], and the Basic Emergency Care course []. The updates also took into account the solid trauma care principles found in other IATSIC resources, such as its National Trauma Management Course and its Definitive Surgical Trauma Care Course []. After completion of the first draft of the revision, independent review was obtained from nine people experienced in various aspects of trauma care in LMICs and who had not been involved in the revision process. Their input was used to further refine the Guidelines .

As with the original 2004 version of the Guidelines , the current version starts with a list of medical goals that should be feasible for most injured persons everywhere. These can be viewed as the “needs of the injured patient” (chapter 3). In order to assure the achievement of such goals, the inputs of human and physical resources must be utilized in an optimal process. To this end, the authors have developed a template for the resources that are needed. These are described in chapters 4 and 5. The authors envision that this template will be used as a guide for those planning trauma treatment services. These Guidelines will hopefully be of relevance to planners in ministries of health, to hospital administrators, to directors of trauma services, to nursing service directors and to clinicians, both individually and collectively, through organizations such as societies of surgery, anesthesia, emergency medicine, traumatology and other disciplines that deal with the injured patient. These groups constitute the target audience for the Guidelines. The Guidelines focus on resource planning for individual facilities. This is part of broader trauma system planning encompassing prehospital care, interfacility transfer, and referral networks [, , ].

This section contains a list of those services which the authors feel are essential to prevent death and disability in injured patients. They might be considered as the “needs of the injured patient.” IATSIC endorses these as the “rights of the injured” and as the responsibility of governments to provide to their people. These can be categorized into three broad sets of needs: Life‐threatening injuries are appropriately treated, promptly and in accordance with appropriate priorities, so as to maximize the likelihood of survival. Potentially disabling injuries are treated appropriately, so as to minimize functional impairment and to maximize the return to independence and to participation in community life. Pain and psychological suffering are minimized. Within these three broad categories, there are several specific medical goals that are eminently achievable within the resources available in most countries. Obstructed airways are opened and maintained before hypoxia leads to death or permanent disability. Impaired breathing is supported until the injured person is able to breathe adequately without assistance. Pneumothorax and hemothorax are promptly recognized and relieved. Bleeding (external or internal) is promptly stopped. Shock is recognized and treated with intravenous (IV) fluid replacement before irreversible consequences occur.

The consequences of traumatic brain injury are lessened by timely decompression of space occupying lesions and by prevention of secondary brain injury. Intestinal and other abdominal injuries are promptly recognized and repaired. Potentially disabling extremity injuries are corrected. Potentially unstable spinal cord injuries are recognized and managed appropriately, including early immobilization. The consequences to the individual of injuries that result in physical impairment are minimized by appropriate rehabilitative services. Medications for the above services and for the minimization of pain are readily available when needed.

The precise procedures that can optimally be applied to achieve these goals, as well as the human and physical resources needed to optimally carry out these procedures, will vary across the spectrum of economic resources of the countries of the world and the geographic location of the facilities concerned. However, these goals should be achievable for most injured patients in most locations. It should also be noted that these goals apply to the entire system and not necessarily all individual facilities. Some of the goals are applicable to all levels of the health care system, especially as regards airway, breathing, and circulation. Some of the above goals would require timely referral from smaller facilities with definitive care mostly be provided at higher level facilities (e.g., decompression of space occupying lesions after head injuries). These details are spelled out in later sections of the Guidelines for EsTC . The provision of these services should not be dependent on ability to pay. Hence, cost recovery schemes, necessary though they may ultimately be, should not preclude the provision of initial emergency care nor of critical elements of definitive care.

The goals outlined in the previous chapter depend on the provision of specific items of physical examination, diagnostic tests, medications and therapeutic procedures. Likewise, the ability of the health system to provide these items depends on the inputs of human resources (training and staffing) and physical resources (equipment and supplies). The following sections of these Guidelines for EsTC outline those resources which the authors feel are essential to the provision of essential trauma services. These resources are outlined in the form of the resource matrix for essential trauma care (Tables , , , , , , , , , , , , , , , ).

The resource matrix for trauma care contains brief descriptions of the resources that need to be available for the provision of specific categories of care at different levels of the health care system. A specific matrix is derived for each of 15 categories of care, such as airway, shock, head injuries, extremity injuries and rehabilitation. These include both initial emergency management and long‐term definitive care.

On the vertical axis of each matrix are listed the specific elements of trauma care that are needed. These are divided into two categories: (1) knowledge and skills and (2) equipment and supplies. See Table as an example. Knowledge and skills imply that the staff (medical, nursing and others) have the requisite training to perform such diagnostic and therapeutic activities safely and successfully. This implies not only the requisite training in their basic education (school and postgraduate training), but also continuing education to maintain these skills. Requirements for continuing education (continuing professional development) are addressed in Table . In some situations, provision of services may require task sharing, with providers performing tasks above their usual level of training. Details of the supplemental training needed in these situations is included, where relevant, in the tables.

Equipment and supplies imply that these items are available to all who need them, without consideration of ability to pay, especially in true life‐threatening emergencies. This implies not only having them physically present in the facility but having them readily available on an ongoing basis; where appropriate, 24 hours a day, 7 days a week. It thus implies that organizational and administrative mechanisms exist to quickly replace depleted or expired stocks of supplies and medications, and to quickly repair non‐functioning equipment. The quality control mechanisms necessary to assure such provision of supplies and to assure the quality of medical care provided are addressed in Table .

The EsTC resource matrix goes into depth on the simple, vital services and related equipment. This is especially so for the immediately life‐threatening injuries to be addressed in the initial evaluation and resuscitation, such as the management of airway, breathing and circulation (Sections , , ). For more complicated services, such as operative care of head, torso or extremity injuries (Sections , , , , , , , , , ), the EsTC resource matrices go into less detail. For most of these more complicated issues, the elements of care to be provided are listed as a general service (e.g., laparotomy for trauma), with a basic discussion of what broad skills and equipment need to be available, but without a detailed, separate delineation of the specific skills or physical materials needed. Details of operating theater instruments, equipment, supplies and infrastructure, and of anesthetic capabilities are beyond the scope of this publication. The availability of a clinical service in these Guidelines implies the expertise and physical materials to carry out that service successfully and safely. In this regard, the reader is also referred to WHO publications on broader surgical and anesthetic issues ( https://www.who.int/teams/integrated‐health‐services/clinical‐services‐and‐systems/surgical‐care ).

On the horizontal axis of each matrix are listed the range of health facilities. It is acknowledged that the division between different levels is somewhat artificial, with actual facilities representing a continuum rather than discrete categories. It is also acknowledged that the capabilities of each level vary significantly between different countries. Working within these constraints, the authors have devised the following categories. Clinic: Typically an outpatient clinic, usually staffed by nurses or mid‐level providers (may be known as physicians assistants, clinical officers, or similar) and occasionally, especially in middle‐income countries, by doctors. Such clinics can see many injured patients, and occasionally seriously injured patients, especially in rural locations with limited pre‐hospital emergency medical services. In the original EsTC , smaller facilities (e.g., village health posts staffed by providers with a few months training) were considered also. However, in this update, we restrict recommendations to clinics staffed by formally‐trained providers such as nurses. First‐level hospital: Smaller hospitals, usually staffed by general doctors. They occasionally have a small number of specialists, such as a general surgeon or emergency physician. Such hospitals may or may not have operating theater capabilities.