The Golden Hour, Revisited

Max D

Corvus Training Group
The Golden Hour, Revisited (from the Emergency Literature of Note Blog)

Medicine is full of “golden” times. tPA, door-to-balloon time, sepsis bundles, and more – as the various time-dependent mandates pile up and resources remain static, it is important to revisit each and prioritize.
These authors are making an observational comment on the “golden hour” as it applies to seriously injured trauma patients. Modern trauma systems have evolved to rapidly funnel patients through the system to the best-equipped facility. This has involved significant investment and resource utilization by aeromedical transport. While glamorous and heroic, unfortunately many patients transported by this inefficient and dangerous method are either too lightly or badly damaged to demonstrate any benefit from alacrity.

These authors, looking at data from a clinical trial concerning early resuscitation fluids, analyze 778 patients with hemorrhagic shock and 1,239 patients with traumatic brain injury. Patients whose pre-hospital time exceeded 60 minutes – the “golden hour” – were no more likely to be dead or neurologically devastated than those who reached the hospital within 60 minutes. Thus, questioning the "golden hour" of trauma.
However, at least, within the hemorrhagic shock group, the subset of 484 patients in which a “critical intervention” was performed within 24 hours of arrival did show a survival advantage – OR 2.37 (95% CI 1.05 to 5.37). It is probably still reasonable to continue transporting those in hypovolemic shock until validated criteria for non-survivability or lack of intervention exist. Traumatic brain injury patients, however, may urgently need to be revisited for the necessity of resource-intensive transport.

This is, additionally, a lovely example of secondary use of clinical trial data. Even though the original trial was stopped early due to futility regarding the primary efficacy endpoint, the re-use of the rigorously collected data redeems the invested resources. High-quality clinical trial data is accumulating rapidly – and perhaps the greatest tragedy in medicine is how much it is locked away as proprietary intellectual property. Share! Share!

“Revisiting the ‘Golden Hour’: An Evaluation of Out-of-Hospital Time in Shock and Traumatic Brain Injury”
I would caution against taking this paper as dismissal of the concept of "the golden hour, which is certainly not the message I took from it.

The way trauma is addressed in the field and in the hospital in the present day has changed phenomenally since the early days of ATLS (1960's), when pre-hospital treatment was rudimentary by comparison with what EMS can do today, and when the concept of a Golden Hour was invented. Rapid EMS response and high level capability in the present day means patients may have two or more large-bore IV's, application of tourniquets, needle thoracostomies, and other lifesaving modalities within minutes of injury, which was unheard of back when the Golden Hour was conceptualized. And this concept has shaped the philosophy and delivery of trauma care in the USA (and elsewhere in the world, more or less), which has been a phenomenal success and has saved a LOT of lives. Those of us who were active in trauma care 25 or more years ago can attest to this fact. Patients would come into the ER in ungodly bad shape, with minimal interventions only applied in the pre-hospital setting.

But you're right, there now seems to be an overwhelming pressure from some quarters to lump ALL trauma patients into the category requiring Priority/Urgent/Rapid Transport to a Level I Trauma Center. I suspect in many cases this is due to the "we've got it, so we're by God gonna use it" mentality. This is particularly evident when you have multiple hospitals with their own helicopter ambulance services competing with each other in the same service area. In my previous hospital (a rural Level III ER) we often had patients who could easily be managed in our facility that bypassed us and were flighted out to a Level II ER for no other reason than the fact that helicopter had been scrambled to the scene (and the only way they were gonna get paid for flight time was if they transported a patient).

I'm not sure what the solution to this waste of resources & dollars might be, but I agree it needs to be looked into.

Max D

Corvus Training Group
I definitely agree that we shouldn't be lackadaisical in our transport, but I believe that as evidence replaces anecdote and as the methods and systems by which we render care improve, the concept of a "[insert precious material] hour" seems less and less applicable. The old trimodal distribution of trauma deaths, as described by Trunkey in 1983 no longer describes the distribution of deaths in modern emergency care settings. Once a surviving trauma patient makes it to a hospital they are far more likely to be successfully resuscitated and stay that way. This means that an overwhelming majority of people die before they ever get to the hospital. Thanks to safety equipment barely keeping pace with the new and interesting ways for people to murder themselves, roughly the same amount of people are dying before prehospital intervention. This shifts the bulk of the "do something" on to the shoulders of pre-hospital practitioners.
The Golden Hour has served its intended purpose in EMS. It was part of the system that transformed us from the meat wagon engineer into the respected professionals we are today. It provided us motivation to expedite on scene assessment and treatment and get underway to definitive treatment in a reasonable amount of time. The concept of the Golden Hour may still be important, but it is certainly no longer an hour. I would say that we should transport our patients as quickly as safely possible to the most appropriate facility by reducing on scene time to an absolute minimum.

1. Trauma deaths in a mature urban trauma system: is "trimodal" distribution a valid concept? ( "The classic "trimodal" distribution of deaths does not apply in our trauma system. Temporal distribution of deaths is influenced by the mechanism of injury, age of the patient, and body area with severe trauma. Knowledge of the time of distribution of deaths might help in allocating trauma resources and focusing research effort."

2. Changing epidemiology of trauma deaths leads to a bimodal distribution. ( "trauma-related deaths now have a largely bimodal, rather than a trimodal, distribution. The greatly diminished late peak in deaths likely implies improvements in resuscitation and critical care. The “golden hour” is real and remains relevant, as a majority of deaths occur rapidly following a severe injury."