Golden hour (medicine)

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In emergency medicine the golden hour is the first sixty minutes after the occurrence of major multi-system trauma. It is widely believed that the victim's chances of survival are greatest if he or she receives definitive care in the operating room within the first hour. Recent scrutiny, however, calls this assertion into question.

1 Origins
2 Basics
3 References and notes

[edit] Origins

The concept of the "golden hour" comes from U.S. military wartime experience, particularly in the Vietnam War.^{[citation needed]} In cases of severe trauma, especially internal bleeding, nothing can replace surgery. In addition, medical complications such as shock may occur if the patient is not managed appropriately and expeditiously.^{[citation needed]} It is therefore necessary to transport victims as fast as possible to specialists who are most often found at a hospital trauma center.^{[citation needed]} Because some injuries can cause a trauma victim to decompensate extremely rapidly, the lag time between injury and treatment should ideally be kept to a bare minimum; over time, this lag time was further clarified to a now-standard time frame of no more than 60 minutes, after which time the survival rate for traumatic patients tends to fall off dramatically.^{[citation needed]}

The late Dr. R Adams Cowley is credited with promoting this concept first as a military surgeon and later as head of the University of Maryland Shock Trauma Center. See Lerner and Moscati^[1], [1], and [2].

While the Golden Hour remains a useful tool in teaching emergency medical services providers the importance of minimizing scene times and rapid transport, recent studies throw the concept into question. The concept was never based on any type of scientific evidence; it was instead an abitrary time given by a single surgeon in the early days of EMS. The "Golden Hour" was never tested until recently, when studies showed that there was indeed a very weak correlation between time into surgery and mortality from trauma. According to Dr. Bryan Bledsoe, the studies did not, however, find any "magical time" or find any evidence to suggest that the Golden Hour is anything but a myth^[2].

There are two types of emergent care conditions with well-documented "Golden Hour"-type timing considerations, however: Thrombosis-induced cerebrovascular accidents (also called CVA or stroke), and Acute Myocardial Infarction, sometimes called a heart attack. In the case of the thrombotic CVA, there is a window of three hours from the onset of the CVA, within which "clot-busting" drugs can be administered to relieve the thrombosis. Since it is not possible to determine whether a given apparent stroke is hemorrhagic or thrombotic in the field, however, emergency care providers are instructed to work to get any patient with a possible stroke into a hospital emergency department within three hours of onset.

In the case of a Heart Attack, rapid interpretation of dysrhythmia, and appropriate management, can prevent some sources of sudden cardiac death. Early recognition of ventricular tachycardia, especially combined with either an automatic external defibrillator (AED) or a Manual Defibrillator and appropriate Advanced Cardiac Life Support (ACLS) access can greatly improve patient outcomes; success rates for defibrillation depend on how rapidly appropriate care can be provided after an event of cardiac ischemia or infarction.

[edit] Basics

[edit] Prehospital care

Prehospital care is limited to the minimum, i.e.

A.B.C (airway, breathing, circulation)
cover wounds
realign ("reduce") broken limbs
protect the spine.

Inserting an intravenous drip must be fast and not delay transportation.

Endotracheal intubation is the only act that may delay the transportation. This prehospital strategy is also called scoop and run (also referred to as load and go or swoop and scoop; the latter reference is most often used by helicopter paramedic teams), as opposed to the stay and play that is more adapted to less severe cases (when there is no severe trauma, the trauma caused by the transportation itself is more important than the gain of time).

MEDEVAC helicopters are often used to move victims to a trauma center within the golden hour.

[edit] Hospital selection

The ambulance must transport the victim to the hospital with the facilities to treat the patient. This is not always the closest hospital, as the closest hospital may lack the facilities or may be overwhelmed by other victims from the same incident (see also triage).

[edit] Limited examination

Third point, only limited examination in the emergency department. If there is no evidence for surgical intervention, only three radiographs should be performed: cervical spine, chest and pelvis.

[edit] Summary

As noted on the University of Maryland Shock Trauma Center's website, "(g)radually, the "Golden Hour" theory was emerging based on the importance of speed as well as skill in operating procedures. As (Dr. Cowley) explained in an interview: "There is a golden hour between life and death. If you are critically injured you have less than 60 minutes to survive. You might not die right then; it may be three days or two weeks later -- but something has happened in your body that is irreparable."

The Golden Hour can be summarized by the 3R rule[3] of Dr. Donald Trunkey, an academic trauma surgeon. It involves:

getting the right patient
to the right place
at the right time

The Discovery Health Channel series The Critical Hour is a documentary-style reality TV program focusing on traumatic injuries and the difference the Golden Hour concept can make in saving lives; among the hospital settings regularly featured on the show is the University of Maryland Shock Trauma Center.

[edit] References and notes

^ Lerner, EB; Moscati (2001). "The Golden Hour: Scientific Fact or Medical "Urban Legend?"". Academic Emergency Medicine 8 (7): 758-760.
^ Bledsoe, Bryan E (2002). "The Golden Hour: Fact or Fiction". Emergency Medical Services 6 (31): 105.