Golden hour -Introduction & Literature Review

“Golden Hour after Trauma”
-Literature review
Dr.Sharad H. Gajuryal
MHA Resident
Hospital Administration

 Introduction
 Objective
 History
 Literature to Support and Refute
Golden Hour
 Conclusion

Introduction
 “Golden Hour”-Term to represent the urgent
need for care of trauma patients.
 Implies that morbidity and mortality are
affected if care not instituted within one hour
of injury

 “The hour immediately following traumatic
injury, in which medical treatment for
preventing irreversible internal damage,
and optimizing the chance of survival is
most effective

 Dr.Donald Trunkey have summarized the
“Golden Hour “by 3R rule i.e Getting the
Right Patient to
Right Place at
Right Time

 Trauma is a Serious injury to the body,
as from physical violence or an accident.
 Trauma is defined as a sudden,
unexpected, dramatic, forceful, or violent
event (Johnson, 2009)

Trauma-Trimodal Distribution
Trauma is the leading cause of death in the first four decades of
life within developing countries. Death from trauma has a
trimodal distribution:
Within seconds to minutes -brain
Minutes to hours (GOLDEN HOUR),
Several days or weeks after the initial injury-MOF/ Sepsis

Trauma Facts
 Management of trauma is a neglected field in
developing nations.
 WHO estimates that 5.8 million deaths annually are
due to injuries, 90% of which occur in developing
countries
Maximum proportion of these deaths occur
before patients even reach the hospital.
 Two third (60.7%) of the accident victims belonged to
the age range of 15 to 44 years.
 This is the economically productive age-group and
major financial support for their families.
 All trauma are not related to road transportation injury.

Objective
 To unpack the origin of golden hour and look
at evidence to refute or support it from
multiple review of the literature searched
manually

 Data Sources :
 Literatures were searched in MEDLINE, HINARI
and Cochrane Library. Studies reporting on
golden hour, prehospital time taken for
emergency medical services and outcome
parameter was included.
 The primary outcome was the influence on
mortality.

History
Origin of the term “Golden Hour” was attributed to
Sir R. Adams Cowley, "Father of Trauma Medicine“-
Founder of Baltimore’s Famous Shock Trauma Institute
“ Cowley’s article in 1975 states ,the first hour
after injury will largely determine a critically-
injured person’s chances for survival.”

 Lerner EB et al,in their literature review determined
the origin of the term “Golden Hour”. Most frequently
the phrase was attributed to R.Adams Cowley. They
cited a series of studies discussing the golden
hour.(1)
 But noticed that those studies were often referenced
to each other and were not accompanied by
supporting data or references.
 They only had little scientific evidence to support
golden hour

 A retrospective cohort study of Dinn MM et al from
trauma registry from 2000-2011 in adult patients with
severe head injuries .
 Study was conducted in urban setting of Australia to
determine the effect of patient arrival within the
golden hour on patient outcomes.
 Study outcomes were in-hospital mortality and
survival to hospital discharge.
 A survival benefit exists in patients arriving earlier to
hospital after severe head injury but the benefit may
extend beyond the golden hour. There was evidence
of improved functional outcomes in patients arriving
within 60 min of injury time.(3)

 A study conducted by Grossman DC et al in
Washington for 6 month period , to a total of 459
major trauma victims .
 A geographic locations was determined for these
subjects.
 Of these, 42% of subjects were injured in urban areas
and the remainder in rural areas. The severity of
injuries, was similar for urban and rural major trauma
patients.
Author concluded that Rural victims were over seven
times more likely to die before arrival if the emergency
medical services' response time was more than 30
minutes.
i.e reduced pre hospital time has been found to be
beneficial in rural trauma patient with long transport

A prospective cohort study data from 146 EMS transport
agencies over a 16 month period from 2005-2007 were
analyzed in trauma patients of North America.
The outcome was in-hospital mortality.
Variable studied were EMS intervals
 activation,
 response,
 on-scene,
 transport, &
 total time
There were 3,656 trauma patients available for analysis, of
whom 806 (22.0%) died. After Multivariate, subgroup and
instrumental analysis, no significant association was found
between time and mortality among injured patient.(2)

 A comparative study done by Xi Xiang Tang et al
focusing upon pre hospital trauma care and its
outcome between Scotland and Germany
showed that the mean time from an injury to
arrival to the emergency department in Scottish
patient (247 min)was longer than Germany
patient (73 min )
 Despite variation in prehospital transfer times and
interventions, no significant difference was
demonstrated in revised trauma score upon
arrival, or for the unadjusted mortality rates.(4)

 Lichtveld et al in Netherland for (1999-2000) 2
years in 507 trauma patients also confirmed that
risk of death is not influenced by time between
the accident and arrival at Hospital,
Rather it is determined by by RTS, age, severe
neurological damage , base excess and
hemoglobin .(5)

 Similar conclusion was found in the study of
Lerner EB et al conducted in 2003 at New
york. City . The study was retrospective and
included 1877 trauma patients.
 Author concluded that patient age, Injury Severity
Score, and Revised Trauma Score all were significant
predictors of trauma patient mortality. And total out-
of-hospital time was not associated with
mortality. (6)

Pons PT et al and blackwell TH et al in trauma
patient in year 2005 and 2002 showed that
survival benefit was identified when the response
time is shorter i.e <5 mins and <4 mins for
patient with high risk of mortality.(7,8)

Some researcher even indicate that a slower smoother
transport to the hospital would be beneficial to patients
and pre hospital providers.
A study conducted in Korea by Chung TN et al ,showed
that during the patient transport rush within golden hour
, increased ambulance speed negatively affects the
quality of chest compression during transportation.

By some estimates, the risk of transportation related injury to EMS workers and
patients are also high during the transportation time in golden hours.
The study conducted by Maguire BJ et al , at Baltimore for period of 5 years
concluded that Emergency workers have a documented fatality rate of 12.5%
among 100000 workers.
These death and injuries largely belong to helicopter and ambulance crashes that
result from the emphasis on shorter pre hospital time frames during golden hour. (9)

Conclusion
 Pre-hospital trauma care service remains a
dynamic field of medicine for care of trauma
patients.
 Several studies have suggested a decrease in
mortality when trauma patients reach
definitive care during the Golden Hour, but
recent research demonstrates no link between
time and survival.
 Due to great heterogeneity in the literature,
confined conclusions cannot be drawn.

 The pressure to arrive at the hospital within the
Golden Hour may increase the number of
emergent transports, which have been
demonstrated to increase the risk for collisions
resulting in injury and fatality.
 Despite the conflicting evidence regarding the golden
hour, rapid transport to medical facility remains the
standard of trauma care.
 The goal should be to get ‘the right patient, to the right
place, at the right time, to receive the right care’
following trauma.

References
 1. Lerner EB, Moscati RM. The golden hour:
Scientific fact or medical “urban legend”? Acad
Emerg Med 2001 Jul;8(7):758–60. [Medline]
 2. Newgard CD, Schmicker RH, Hedges JR at
al. Emergency medical service intervals and
survival in trauma: assessment of the ‘golden
hour’ in a North American prospective cohort. Ann
of Emerg Med 2010;55(3):235-46. [Medline]
 3. Dinh MM, Bein K, Roncal S, Byrne CM,
Petchell J, Brennan J. Redefining the golden hour
for severe head injury in an urban setting: The
effect of prehospital arrival times on patient
outcomes. Injury (2012),
doi:10.1016/j.injury.2012.01.011 (in press)

 4. Tan XX, Clement ND, Frink M et al. Pre-hospital trauma
care: A comparison of two healthcare systems. Indian J
Crit Care Med 2012;16:22-7. [Medline]
 5. Lichtveld RA, Panhuizen IF, Smit RBJ et al. Predictors of
death in trauma patients who are alive on arrival to
hospital. European Journal of Trauma and Emergency
Surgery. 2007;33:46-51.
 6. Is total out-of-hospital time a significant predictor of
trauma patient mortality?
Lerner EB1, Billittier AJ, Dorn JM, Wu YW
 7. Response time effectiveness: comparison of response time and
survival in an urban emergency medical services system.
Blackwell TH1, Kaufman JS.
 8. Paramedic response time: does it affect patient survival?
Pons PT1, Haukoos JS, Bludworth W, Cribley T, Pons KA,
Markovchick VJ.

 9. Occupational fatalities in emergency medical services: a
hidden crisis.
Maguire BJ1, Hunting KL, Smith GS, Levick NR.

Golden hour -Introduction & Literature Review

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Golden hour -Introduction & Literature Review