Trauma Mortality and the Golden Hour

Reviewed and revised 3 April 2015

OVERVIEW

• Trauma is a major cause of morbidity and mortality, especially in the <40 years-old age group
• Trauma deaths are classically described as having a trimodal pattern (this is controversial)
• The ‘golden hour’ is term often used in trauma to suggest that an injured patient has 60 minutes from time of injury to receive definitive care, after which morbidity and mortality significantly increase

TRAUMA MORBIDITY AND MORTALITY

Trauma is the leading cause of death under the age of 40 years in developed countries. It is also a major killer of older age groups, behind cardiovascular disease and cancer.

• Most victims are young males
• There is a massive additional societal burden from morbidity affecting survivors as well
• Most preventable deaths are due to hemorrhage

TRIMODAL PATTERN OF MORTALITY

Trauma deaths are classically described as having a trimodal distribution:

• immediate
• early
• late

Immediate deaths

• Seconds to minutes after injury
• Usually unpreventable eg: apnoea secondary to high spinal or brain injury, or catastrophic hemorrhage due to great vessel disruption

Early deaths

• Minutes to hours after injury
• Usually haemorrhage related
• ATLS style emergency care specifically targets these patients.

Late deaths

• Days to weeks after injury
• Usually due to multi-organ failure or sepsis
• Optimal early management may prevent these

As with most things that are ‘classic’, whether this schema matches reality is highly questionable (see Wyatt et al, 1995; Demetriades et al, 2005; Gunst et al, 2010)…

THE GOLDEN HOUR

• The term “golden hour” is widely attributed to R. Adams Cowley, founder of Baltimore’s renowned Shock Trauma Institute, who in a 1975 article stated, “the first hour after injury will largely determine a critically injured person’s chances for survival” – this was in an era characterised by a lack of an organised trauma system and inadequate prehospital care.
• The validity of this concept remains controversial
• An analogous concept, the “platinum 10 minutes” places a time constraint on the pre-hospital care of seriously injured patients: no patient should have more than 10 min of scene-time stabilization by the prehospital team prior to transport to definitive care at a trauma centre.

Implications

• A result of the concept is the preference for a ‘scoop and run’ approach to prehospital care rather than “stay and play” — so that patient’s are transferred to hospital for definitive care as soon as possible.
• Rapid transit to hospital remains the standard of care
• However, there are downsides to massive trauma systems with ‘scoop and run’ approach
  • cost of trauma system
  • risk of transport-related injury (e.g. motor vehicle crashes)
  • delayed or impaired therapy (e.g. chest compressions)
• However, potentially life-saving interventions that can be provided in the field by skilled practitioners should not be delayed
• In a country as large as Australia, retrieval times to centres capable of providing definitive care for trauma can be prolonged (e.g. a mean of 6+ hours in the Top End of the Northern Territory)

Evidence

• observational studies in the 1990s and 2000s found associations between scene times and mortality, as well as response times and mortality (studies were heterogenous, and some included non-traumatic cardiac arrest victims)
• since 2010 numerous observational studies (in USA, Canada, Germany, Italy) have failed to find significant survival advantage for trauma patients with shorter pre-hospital rescue times

Summary

• The ‘golden hour’ isn’t a strictly defined time period
• It is a concept that emphasises the urgency of care required by major trauma patients to prevent ‘early deaths’ predominantly from haemorrhage
• As such it probably remains valid, but for some patients the ‘golden hour’ may only be minutes, or for others, much later
• Discrediting the ‘golden hour’ concept might have implications for trauma system funding and organisation

References and Links

FOAM and web resources

• Resus.ME — London trauma deaths described
• Resus.ME — Scene time not linked to outcome in a large chort
• Trauma Professional’s Blog — Trauma activation patients staying too long in your ED?

Journal articles

• Cowley RA. A total emergency medical system for the State of Maryland. Md State Med J. 1975 Jul;24(7):37-45. PMID: 1142842.
• Rogers FB, Rittenhouse KJ, Gross BW. The golden hour in trauma: Dogma or medical folklore? Injury. 2015 Apr;46(4):525-7. PMID: 25262329.
• Demetriades D, Kimbrell B, Salim A, Velmahos G, Rhee P, Preston C, Gruzinski G, Chan L. Trauma deaths in a mature urban trauma system: is “trimodal” distribution a valid concept? J Am Coll Surg. 2005 Sep;201(3):343-8. PMID: 16125066.
• Gunst M, Ghaemmaghami V, Gruszecki A, Urban J, Frankel H, Shafi S. Changing epidemiology of trauma deaths leads to a bimodal distribution. Proc (Bayl Univ Med Cent). 2010 Oct;23(4):349-54. PMC2943446.
• Lerner EB, Moscati RM. The golden hour: scientific fact or medical “urban legend”? Acad Emerg Med. 2001 Jul;8(7):758-60. PMID: 11435197. [Free Full Text pdf]
• Wyatt J, Beard D, Gray A, Busuttil A, Robertson C. The time of death after trauma. BMJ. 1995 Jun 10;310(6993):1502. PMC2549879.