The Golden Hour

 

The Golden Hour

GoldenHourMore a concept than an actuality, the golden hour was devised in the early days of trauma research and is credited to Dr. R Adams Crowley, widely considered the father of trauma surgery. 

It is clear that the earlier a severely injured patient is brought to definitive therapy, the better the outcome. Once an injury occurs, the clock can be said to start running as regards additional, or secondary, injury. Blood is lost, breathing may be compromised, open cuts and abrasions invite infection, and internal injuries may lead to the loss of the normal internal milieu—by which is meant the normal physiologic environment. For example, rupture of the colon will spill fecal matter into the space around the intestines (the peritoneal cavity), potentially leading to peritonitis (a life threatening infection of the abdominal cavity). A crush injury to the arm or leg might lead to buildup of waste products in the local tissues (surrounding skin, fat, and especially muscle) if the blood flow is compromised. This waste buildup, a toxic stew, leads to further damage.

In another example, injury to the kidneys not only leads to bleeding (which can be severe since the kidneys are so well vascularized) but also to the spillage of urine. Rupture of the stomach can spill caustic digestive juices, including hydrochloric acid (leading to chemical burns and decomposition) into the abdominal cavity. Rupture of a lung can produce pneumothorax, wherein the lung collapses and is no longer effective at oxygenating the blood, with obvious ramifications. A tension pneumothorax, wherein each inhaled breath leads to progressive overinflation of the chest with resultant compression of the heart, is especially dangerous and often immediately life-threatening.

All of these entities and many more are likely to make their appearance in the first minutes or several hours after injury. In addition, once shock sets in, damage is progressive and ongoing. Shock has many definitions, the common denominator of which is a situation in which the tissues of the body are inadequately supplied with oxygen. It may come about as a result of circulatory collapse from loss of blood, a damaged heart no longer capable of pumping (as in heart attack), or perhaps from an absence of adequate oxygen in the blood (damaged lung, choking) or the environment (drowning, asphyxia, etc). The list goes on. 

The idea behind the golden hour is simply this: the sooner a patient gets to definitive medical care, the better. Definitive medical care is generally defined, in modern parlance, as a skilled trauma center with quick access to appropriate specialists, which might include neurosurgeons, trauma surgeons, orthopedic surgeons, critical care specialists, anesthesiologists, and imaging resources such as CT, MRI, etc. Note that this criteria often suggests a patient should be taken to the nearest trauma center and not the nearest hospital. This, in fact, is true and has lead to the modern system of designated trauma centers in most cities and regions of the United States.

Despite the term, it has come to be recognized that there is likely not an increased mortality after 60 minutes. The concept is a general one, in that there is increased mortality with increasing time after injury, whether it be 60 minutes or three hours. The term golden hour is a good one though, in that it continues to emphasize the importance of getting a severely injured patient to definitive care as quickly as possible. It also emphasizes prehospital care by EMTs, paramedics, etc. The concept, in practice, has saved countless lives, whether it be on the streets of inner city America—or the battlefields of Iraq and Afghanistan.

 

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