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Golden hour -Introduction & Literature Review

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Golden hour -Introduction & Literature Review

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Golden hour -Introduction & Literature Review

  1. 1. “Golden Hour after Trauma” -Literature review Dr.Sharad H. Gajuryal MHA Resident Hospital Administration
  2. 2.  Introduction  Objective  History  Literature to Support and Refute Golden Hour  Conclusion
  3. 3. 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
  4. 4.  “The hour immediately following traumatic injury, in which medical treatment for preventing irreversible internal damage, and optimizing the chance of survival is most effective
  5. 5.  Dr.Donald Trunkey have summarized the “Golden Hour “by 3R rule i.e Getting the Right Patient to Right Place at Right Time
  6. 6.  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)
  7. 7. 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
  8. 8. 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.
  9. 9. 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
  10. 10.  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.
  11. 11. 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.”
  12. 12.  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
  13. 13.  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)
  14. 14.  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
  15. 15. 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)
  16. 16.  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)
  17. 17.  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)
  18. 18.  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)
  19. 19. 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)
  20. 20. 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.
  21. 21. 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)
  22. 22. 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.
  23. 23.  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.
  24. 24. 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)
  25. 25.  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.
  26. 26.  9. Occupational fatalities in emergency medical services: a hidden crisis. Maguire BJ1, Hunting KL, Smith GS, Levick NR.

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