Trauma Mortality and the Golden Hour

98
SHARES
FacebookTwitterSubscribe

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 (the golden hour)

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 Baltimores renowned
Shock Trauma Institute, who in a 1975 article stated, the first hour after injury will largely
determine a critically injured persons 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 patients 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 isnt 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