ldquoGolden Hour after Traumardquo
-Literature review
DrSharad H Gajuryal
MHA Resident
Hospital Administration
Introduction
Objective
History
Literature to Support and Refute
Golden Hour
Conclusion
Introduction
ldquoGolden Hourrdquo-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
ldquoThe hour immediately following traumatic
injury in which medical treatment for
preventing irreversible internal damage
and optimizing the chance of survival is
most effective
DrDonald Trunkey have summarized the
ldquoGolden Hour ldquoby 3R rule ie Getting the
Right Patient to
Right Place at
Right Time
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)
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
Trauma Facts Management of trauma is a neglected field in
developing nations
WHO estimates that 58 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 (607) 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
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
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
History
Origin of the term ldquoGolden Hourrdquo was attributed to
Sir R Adams Cowley Father of Trauma Medicineldquo-
Founder of Baltimorersquos Famous Shock Trauma Institute
ldquo Cowleyrsquos article in 1975 states the first hour
after injury will largely determine a critically-
injured personrsquos chances for survivalrdquo
Lerner EB et alin their literature review determined
the origin of the term ldquoGolden Hourrdquo Most frequently
the phrase was attributed to RAdams 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
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)
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
ie reduced pre hospital time has been found to be beneficial in rural trauma patient with long transport time
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 amp
total time
There were 3656 trauma patients available for analysis of whom 806 (220) died After Multivariate subgroup and instrumental analysis no significant association was found between time and mortality among injured patient(2)
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)
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)
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)
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 ie lt5 mins and lt4 mins for
patient with high risk of mortality(78)
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
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 125
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)
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
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 lsquothe right patient to the right
place at the right time to receive the right carersquo
following trauma
References 1 Lerner EB Moscati RM The golden hour
Scientific fact or medical ldquourban legendrdquo AcadEmerg Med 2001 Jul8(7)758ndash60 [Medline]
2 Newgard CD Schmicker RH Hedges JR at al Emergency medical service intervals and survival in trauma assessment of the lsquogolden hourrsquo in a North American prospective cohort Ann of Emerg Med 201055(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) doi101016jinjury201201011 (in press)
4 Tan XX Clement ND Frink M et al Pre-hospital trauma care A comparison of two healthcare systems Indian J Crit Care Med 20121622-7 [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 20073346-51
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
9 Occupational fatalities in emergency medical services a
hidden crisis
Maguire BJ1 Hunting KL Smith GS Levick NR
Introduction
Objective
History
Literature to Support and Refute
Golden Hour
Conclusion
Introduction
ldquoGolden Hourrdquo-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
ldquoThe hour immediately following traumatic
injury in which medical treatment for
preventing irreversible internal damage
and optimizing the chance of survival is
most effective
DrDonald Trunkey have summarized the
ldquoGolden Hour ldquoby 3R rule ie Getting the
Right Patient to
Right Place at
Right Time
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)
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
Trauma Facts Management of trauma is a neglected field in
developing nations
WHO estimates that 58 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 (607) 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
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
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
History
Origin of the term ldquoGolden Hourrdquo was attributed to
Sir R Adams Cowley Father of Trauma Medicineldquo-
Founder of Baltimorersquos Famous Shock Trauma Institute
ldquo Cowleyrsquos article in 1975 states the first hour
after injury will largely determine a critically-
injured personrsquos chances for survivalrdquo
Lerner EB et alin their literature review determined
the origin of the term ldquoGolden Hourrdquo Most frequently
the phrase was attributed to RAdams 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
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)
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
ie reduced pre hospital time has been found to be beneficial in rural trauma patient with long transport time
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 amp
total time
There were 3656 trauma patients available for analysis of whom 806 (220) died After Multivariate subgroup and instrumental analysis no significant association was found between time and mortality among injured patient(2)
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)
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)
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)
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 ie lt5 mins and lt4 mins for
patient with high risk of mortality(78)
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
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 125
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)
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
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 lsquothe right patient to the right
place at the right time to receive the right carersquo
following trauma
References 1 Lerner EB Moscati RM The golden hour
Scientific fact or medical ldquourban legendrdquo AcadEmerg Med 2001 Jul8(7)758ndash60 [Medline]
2 Newgard CD Schmicker RH Hedges JR at al Emergency medical service intervals and survival in trauma assessment of the lsquogolden hourrsquo in a North American prospective cohort Ann of Emerg Med 201055(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) doi101016jinjury201201011 (in press)
4 Tan XX Clement ND Frink M et al Pre-hospital trauma care A comparison of two healthcare systems Indian J Crit Care Med 20121622-7 [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 20073346-51
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
9 Occupational fatalities in emergency medical services a
hidden crisis
Maguire BJ1 Hunting KL Smith GS Levick NR
Introduction
ldquoGolden Hourrdquo-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
ldquoThe hour immediately following traumatic
injury in which medical treatment for
preventing irreversible internal damage
and optimizing the chance of survival is
most effective
DrDonald Trunkey have summarized the
ldquoGolden Hour ldquoby 3R rule ie Getting the
Right Patient to
Right Place at
Right Time
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)
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
Trauma Facts Management of trauma is a neglected field in
developing nations
WHO estimates that 58 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 (607) 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
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
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
History
Origin of the term ldquoGolden Hourrdquo was attributed to
Sir R Adams Cowley Father of Trauma Medicineldquo-
Founder of Baltimorersquos Famous Shock Trauma Institute
ldquo Cowleyrsquos article in 1975 states the first hour
after injury will largely determine a critically-
injured personrsquos chances for survivalrdquo
Lerner EB et alin their literature review determined
the origin of the term ldquoGolden Hourrdquo Most frequently
the phrase was attributed to RAdams 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
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)
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
ie reduced pre hospital time has been found to be beneficial in rural trauma patient with long transport time
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 amp
total time
There were 3656 trauma patients available for analysis of whom 806 (220) died After Multivariate subgroup and instrumental analysis no significant association was found between time and mortality among injured patient(2)
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)
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)
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)
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 ie lt5 mins and lt4 mins for
patient with high risk of mortality(78)
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
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 125
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)
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
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 lsquothe right patient to the right
place at the right time to receive the right carersquo
following trauma
References 1 Lerner EB Moscati RM The golden hour
Scientific fact or medical ldquourban legendrdquo AcadEmerg Med 2001 Jul8(7)758ndash60 [Medline]
2 Newgard CD Schmicker RH Hedges JR at al Emergency medical service intervals and survival in trauma assessment of the lsquogolden hourrsquo in a North American prospective cohort Ann of Emerg Med 201055(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) doi101016jinjury201201011 (in press)
4 Tan XX Clement ND Frink M et al Pre-hospital trauma care A comparison of two healthcare systems Indian J Crit Care Med 20121622-7 [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 20073346-51
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
9 Occupational fatalities in emergency medical services a
hidden crisis
Maguire BJ1 Hunting KL Smith GS Levick NR
ldquoThe hour immediately following traumatic
injury in which medical treatment for
preventing irreversible internal damage
and optimizing the chance of survival is
most effective
DrDonald Trunkey have summarized the
ldquoGolden Hour ldquoby 3R rule ie Getting the
Right Patient to
Right Place at
Right Time
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)
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
Trauma Facts Management of trauma is a neglected field in
developing nations
WHO estimates that 58 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 (607) 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
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
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
History
Origin of the term ldquoGolden Hourrdquo was attributed to
Sir R Adams Cowley Father of Trauma Medicineldquo-
Founder of Baltimorersquos Famous Shock Trauma Institute
ldquo Cowleyrsquos article in 1975 states the first hour
after injury will largely determine a critically-
injured personrsquos chances for survivalrdquo
Lerner EB et alin their literature review determined
the origin of the term ldquoGolden Hourrdquo Most frequently
the phrase was attributed to RAdams 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
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)
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
ie reduced pre hospital time has been found to be beneficial in rural trauma patient with long transport time
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 amp
total time
There were 3656 trauma patients available for analysis of whom 806 (220) died After Multivariate subgroup and instrumental analysis no significant association was found between time and mortality among injured patient(2)
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)
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)
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)
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 ie lt5 mins and lt4 mins for
patient with high risk of mortality(78)
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
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 125
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)
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
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 lsquothe right patient to the right
place at the right time to receive the right carersquo
following trauma
References 1 Lerner EB Moscati RM The golden hour
Scientific fact or medical ldquourban legendrdquo AcadEmerg Med 2001 Jul8(7)758ndash60 [Medline]
2 Newgard CD Schmicker RH Hedges JR at al Emergency medical service intervals and survival in trauma assessment of the lsquogolden hourrsquo in a North American prospective cohort Ann of Emerg Med 201055(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) doi101016jinjury201201011 (in press)
4 Tan XX Clement ND Frink M et al Pre-hospital trauma care A comparison of two healthcare systems Indian J Crit Care Med 20121622-7 [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 20073346-51
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
9 Occupational fatalities in emergency medical services a
hidden crisis
Maguire BJ1 Hunting KL Smith GS Levick NR
DrDonald Trunkey have summarized the
ldquoGolden Hour ldquoby 3R rule ie Getting the
Right Patient to
Right Place at
Right Time
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)
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
Trauma Facts Management of trauma is a neglected field in
developing nations
WHO estimates that 58 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 (607) 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
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
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
History
Origin of the term ldquoGolden Hourrdquo was attributed to
Sir R Adams Cowley Father of Trauma Medicineldquo-
Founder of Baltimorersquos Famous Shock Trauma Institute
ldquo Cowleyrsquos article in 1975 states the first hour
after injury will largely determine a critically-
injured personrsquos chances for survivalrdquo
Lerner EB et alin their literature review determined
the origin of the term ldquoGolden Hourrdquo Most frequently
the phrase was attributed to RAdams 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
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)
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
ie reduced pre hospital time has been found to be beneficial in rural trauma patient with long transport time
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 amp
total time
There were 3656 trauma patients available for analysis of whom 806 (220) died After Multivariate subgroup and instrumental analysis no significant association was found between time and mortality among injured patient(2)
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)
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)
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)
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 ie lt5 mins and lt4 mins for
patient with high risk of mortality(78)
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
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 125
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)
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
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 lsquothe right patient to the right
place at the right time to receive the right carersquo
following trauma
References 1 Lerner EB Moscati RM The golden hour
Scientific fact or medical ldquourban legendrdquo AcadEmerg Med 2001 Jul8(7)758ndash60 [Medline]
2 Newgard CD Schmicker RH Hedges JR at al Emergency medical service intervals and survival in trauma assessment of the lsquogolden hourrsquo in a North American prospective cohort Ann of Emerg Med 201055(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) doi101016jinjury201201011 (in press)
4 Tan XX Clement ND Frink M et al Pre-hospital trauma care A comparison of two healthcare systems Indian J Crit Care Med 20121622-7 [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 20073346-51
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
9 Occupational fatalities in emergency medical services a
hidden crisis
Maguire BJ1 Hunting KL Smith GS Levick NR
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)
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
Trauma Facts Management of trauma is a neglected field in
developing nations
WHO estimates that 58 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 (607) 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
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
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
History
Origin of the term ldquoGolden Hourrdquo was attributed to
Sir R Adams Cowley Father of Trauma Medicineldquo-
Founder of Baltimorersquos Famous Shock Trauma Institute
ldquo Cowleyrsquos article in 1975 states the first hour
after injury will largely determine a critically-
injured personrsquos chances for survivalrdquo
Lerner EB et alin their literature review determined
the origin of the term ldquoGolden Hourrdquo Most frequently
the phrase was attributed to RAdams 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
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)
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
ie reduced pre hospital time has been found to be beneficial in rural trauma patient with long transport time
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 amp
total time
There were 3656 trauma patients available for analysis of whom 806 (220) died After Multivariate subgroup and instrumental analysis no significant association was found between time and mortality among injured patient(2)
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)
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)
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)
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 ie lt5 mins and lt4 mins for
patient with high risk of mortality(78)
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
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 125
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)
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
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 lsquothe right patient to the right
place at the right time to receive the right carersquo
following trauma
References 1 Lerner EB Moscati RM The golden hour
Scientific fact or medical ldquourban legendrdquo AcadEmerg Med 2001 Jul8(7)758ndash60 [Medline]
2 Newgard CD Schmicker RH Hedges JR at al Emergency medical service intervals and survival in trauma assessment of the lsquogolden hourrsquo in a North American prospective cohort Ann of Emerg Med 201055(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) doi101016jinjury201201011 (in press)
4 Tan XX Clement ND Frink M et al Pre-hospital trauma care A comparison of two healthcare systems Indian J Crit Care Med 20121622-7 [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 20073346-51
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
9 Occupational fatalities in emergency medical services a
hidden crisis
Maguire BJ1 Hunting KL Smith GS Levick NR
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
Trauma Facts Management of trauma is a neglected field in
developing nations
WHO estimates that 58 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 (607) 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
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
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
History
Origin of the term ldquoGolden Hourrdquo was attributed to
Sir R Adams Cowley Father of Trauma Medicineldquo-
Founder of Baltimorersquos Famous Shock Trauma Institute
ldquo Cowleyrsquos article in 1975 states the first hour
after injury will largely determine a critically-
injured personrsquos chances for survivalrdquo
Lerner EB et alin their literature review determined
the origin of the term ldquoGolden Hourrdquo Most frequently
the phrase was attributed to RAdams 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
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)
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
ie reduced pre hospital time has been found to be beneficial in rural trauma patient with long transport time
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 amp
total time
There were 3656 trauma patients available for analysis of whom 806 (220) died After Multivariate subgroup and instrumental analysis no significant association was found between time and mortality among injured patient(2)
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)
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)
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)
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 ie lt5 mins and lt4 mins for
patient with high risk of mortality(78)
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
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 125
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)
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
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 lsquothe right patient to the right
place at the right time to receive the right carersquo
following trauma
References 1 Lerner EB Moscati RM The golden hour
Scientific fact or medical ldquourban legendrdquo AcadEmerg Med 2001 Jul8(7)758ndash60 [Medline]
2 Newgard CD Schmicker RH Hedges JR at al Emergency medical service intervals and survival in trauma assessment of the lsquogolden hourrsquo in a North American prospective cohort Ann of Emerg Med 201055(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) doi101016jinjury201201011 (in press)
4 Tan XX Clement ND Frink M et al Pre-hospital trauma care A comparison of two healthcare systems Indian J Crit Care Med 20121622-7 [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 20073346-51
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
9 Occupational fatalities in emergency medical services a
hidden crisis
Maguire BJ1 Hunting KL Smith GS Levick NR
Trauma Facts Management of trauma is a neglected field in
developing nations
WHO estimates that 58 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 (607) 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
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
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
History
Origin of the term ldquoGolden Hourrdquo was attributed to
Sir R Adams Cowley Father of Trauma Medicineldquo-
Founder of Baltimorersquos Famous Shock Trauma Institute
ldquo Cowleyrsquos article in 1975 states the first hour
after injury will largely determine a critically-
injured personrsquos chances for survivalrdquo
Lerner EB et alin their literature review determined
the origin of the term ldquoGolden Hourrdquo Most frequently
the phrase was attributed to RAdams 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
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)
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
ie reduced pre hospital time has been found to be beneficial in rural trauma patient with long transport time
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 amp
total time
There were 3656 trauma patients available for analysis of whom 806 (220) died After Multivariate subgroup and instrumental analysis no significant association was found between time and mortality among injured patient(2)
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)
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)
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)
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 ie lt5 mins and lt4 mins for
patient with high risk of mortality(78)
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
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 125
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)
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
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 lsquothe right patient to the right
place at the right time to receive the right carersquo
following trauma
References 1 Lerner EB Moscati RM The golden hour
Scientific fact or medical ldquourban legendrdquo AcadEmerg Med 2001 Jul8(7)758ndash60 [Medline]
2 Newgard CD Schmicker RH Hedges JR at al Emergency medical service intervals and survival in trauma assessment of the lsquogolden hourrsquo in a North American prospective cohort Ann of Emerg Med 201055(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) doi101016jinjury201201011 (in press)
4 Tan XX Clement ND Frink M et al Pre-hospital trauma care A comparison of two healthcare systems Indian J Crit Care Med 20121622-7 [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 20073346-51
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
9 Occupational fatalities in emergency medical services a
hidden crisis
Maguire BJ1 Hunting KL Smith GS Levick NR
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
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
History
Origin of the term ldquoGolden Hourrdquo was attributed to
Sir R Adams Cowley Father of Trauma Medicineldquo-
Founder of Baltimorersquos Famous Shock Trauma Institute
ldquo Cowleyrsquos article in 1975 states the first hour
after injury will largely determine a critically-
injured personrsquos chances for survivalrdquo
Lerner EB et alin their literature review determined
the origin of the term ldquoGolden Hourrdquo Most frequently
the phrase was attributed to RAdams 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
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)
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
ie reduced pre hospital time has been found to be beneficial in rural trauma patient with long transport time
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 amp
total time
There were 3656 trauma patients available for analysis of whom 806 (220) died After Multivariate subgroup and instrumental analysis no significant association was found between time and mortality among injured patient(2)
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)
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)
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)
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 ie lt5 mins and lt4 mins for
patient with high risk of mortality(78)
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
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 125
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)
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
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 lsquothe right patient to the right
place at the right time to receive the right carersquo
following trauma
References 1 Lerner EB Moscati RM The golden hour
Scientific fact or medical ldquourban legendrdquo AcadEmerg Med 2001 Jul8(7)758ndash60 [Medline]
2 Newgard CD Schmicker RH Hedges JR at al Emergency medical service intervals and survival in trauma assessment of the lsquogolden hourrsquo in a North American prospective cohort Ann of Emerg Med 201055(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) doi101016jinjury201201011 (in press)
4 Tan XX Clement ND Frink M et al Pre-hospital trauma care A comparison of two healthcare systems Indian J Crit Care Med 20121622-7 [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 20073346-51
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
9 Occupational fatalities in emergency medical services a
hidden crisis
Maguire BJ1 Hunting KL Smith GS Levick NR
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
History
Origin of the term ldquoGolden Hourrdquo was attributed to
Sir R Adams Cowley Father of Trauma Medicineldquo-
Founder of Baltimorersquos Famous Shock Trauma Institute
ldquo Cowleyrsquos article in 1975 states the first hour
after injury will largely determine a critically-
injured personrsquos chances for survivalrdquo
Lerner EB et alin their literature review determined
the origin of the term ldquoGolden Hourrdquo Most frequently
the phrase was attributed to RAdams 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
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)
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
ie reduced pre hospital time has been found to be beneficial in rural trauma patient with long transport time
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 amp
total time
There were 3656 trauma patients available for analysis of whom 806 (220) died After Multivariate subgroup and instrumental analysis no significant association was found between time and mortality among injured patient(2)
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)
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)
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)
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 ie lt5 mins and lt4 mins for
patient with high risk of mortality(78)
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
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 125
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)
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
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 lsquothe right patient to the right
place at the right time to receive the right carersquo
following trauma
References 1 Lerner EB Moscati RM The golden hour
Scientific fact or medical ldquourban legendrdquo AcadEmerg Med 2001 Jul8(7)758ndash60 [Medline]
2 Newgard CD Schmicker RH Hedges JR at al Emergency medical service intervals and survival in trauma assessment of the lsquogolden hourrsquo in a North American prospective cohort Ann of Emerg Med 201055(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) doi101016jinjury201201011 (in press)
4 Tan XX Clement ND Frink M et al Pre-hospital trauma care A comparison of two healthcare systems Indian J Crit Care Med 20121622-7 [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 20073346-51
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
9 Occupational fatalities in emergency medical services a
hidden crisis
Maguire BJ1 Hunting KL Smith GS Levick NR
History
Origin of the term ldquoGolden Hourrdquo was attributed to
Sir R Adams Cowley Father of Trauma Medicineldquo-
Founder of Baltimorersquos Famous Shock Trauma Institute
ldquo Cowleyrsquos article in 1975 states the first hour
after injury will largely determine a critically-
injured personrsquos chances for survivalrdquo
Lerner EB et alin their literature review determined
the origin of the term ldquoGolden Hourrdquo Most frequently
the phrase was attributed to RAdams 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
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)
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
ie reduced pre hospital time has been found to be beneficial in rural trauma patient with long transport time
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 amp
total time
There were 3656 trauma patients available for analysis of whom 806 (220) died After Multivariate subgroup and instrumental analysis no significant association was found between time and mortality among injured patient(2)
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)
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)
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)
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 ie lt5 mins and lt4 mins for
patient with high risk of mortality(78)
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
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 125
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)
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
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 lsquothe right patient to the right
place at the right time to receive the right carersquo
following trauma
References 1 Lerner EB Moscati RM The golden hour
Scientific fact or medical ldquourban legendrdquo AcadEmerg Med 2001 Jul8(7)758ndash60 [Medline]
2 Newgard CD Schmicker RH Hedges JR at al Emergency medical service intervals and survival in trauma assessment of the lsquogolden hourrsquo in a North American prospective cohort Ann of Emerg Med 201055(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) doi101016jinjury201201011 (in press)
4 Tan XX Clement ND Frink M et al Pre-hospital trauma care A comparison of two healthcare systems Indian J Crit Care Med 20121622-7 [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 20073346-51
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
9 Occupational fatalities in emergency medical services a
hidden crisis
Maguire BJ1 Hunting KL Smith GS Levick NR
Lerner EB et alin their literature review determined
the origin of the term ldquoGolden Hourrdquo Most frequently
the phrase was attributed to RAdams 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
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)
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
ie reduced pre hospital time has been found to be beneficial in rural trauma patient with long transport time
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 amp
total time
There were 3656 trauma patients available for analysis of whom 806 (220) died After Multivariate subgroup and instrumental analysis no significant association was found between time and mortality among injured patient(2)
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)
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)
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)
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 ie lt5 mins and lt4 mins for
patient with high risk of mortality(78)
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
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 125
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)
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
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 lsquothe right patient to the right
place at the right time to receive the right carersquo
following trauma
References 1 Lerner EB Moscati RM The golden hour
Scientific fact or medical ldquourban legendrdquo AcadEmerg Med 2001 Jul8(7)758ndash60 [Medline]
2 Newgard CD Schmicker RH Hedges JR at al Emergency medical service intervals and survival in trauma assessment of the lsquogolden hourrsquo in a North American prospective cohort Ann of Emerg Med 201055(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) doi101016jinjury201201011 (in press)
4 Tan XX Clement ND Frink M et al Pre-hospital trauma care A comparison of two healthcare systems Indian J Crit Care Med 20121622-7 [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 20073346-51
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
9 Occupational fatalities in emergency medical services a
hidden crisis
Maguire BJ1 Hunting KL Smith GS Levick NR
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)
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
ie reduced pre hospital time has been found to be beneficial in rural trauma patient with long transport time
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 amp
total time
There were 3656 trauma patients available for analysis of whom 806 (220) died After Multivariate subgroup and instrumental analysis no significant association was found between time and mortality among injured patient(2)
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)
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)
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)
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 ie lt5 mins and lt4 mins for
patient with high risk of mortality(78)
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
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 125
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)
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
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 lsquothe right patient to the right
place at the right time to receive the right carersquo
following trauma
References 1 Lerner EB Moscati RM The golden hour
Scientific fact or medical ldquourban legendrdquo AcadEmerg Med 2001 Jul8(7)758ndash60 [Medline]
2 Newgard CD Schmicker RH Hedges JR at al Emergency medical service intervals and survival in trauma assessment of the lsquogolden hourrsquo in a North American prospective cohort Ann of Emerg Med 201055(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) doi101016jinjury201201011 (in press)
4 Tan XX Clement ND Frink M et al Pre-hospital trauma care A comparison of two healthcare systems Indian J Crit Care Med 20121622-7 [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 20073346-51
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
9 Occupational fatalities in emergency medical services a
hidden crisis
Maguire BJ1 Hunting KL Smith GS Levick NR
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
ie reduced pre hospital time has been found to be beneficial in rural trauma patient with long transport time
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 amp
total time
There were 3656 trauma patients available for analysis of whom 806 (220) died After Multivariate subgroup and instrumental analysis no significant association was found between time and mortality among injured patient(2)
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)
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)
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)
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 ie lt5 mins and lt4 mins for
patient with high risk of mortality(78)
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
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 125
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)
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
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 lsquothe right patient to the right
place at the right time to receive the right carersquo
following trauma
References 1 Lerner EB Moscati RM The golden hour
Scientific fact or medical ldquourban legendrdquo AcadEmerg Med 2001 Jul8(7)758ndash60 [Medline]
2 Newgard CD Schmicker RH Hedges JR at al Emergency medical service intervals and survival in trauma assessment of the lsquogolden hourrsquo in a North American prospective cohort Ann of Emerg Med 201055(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) doi101016jinjury201201011 (in press)
4 Tan XX Clement ND Frink M et al Pre-hospital trauma care A comparison of two healthcare systems Indian J Crit Care Med 20121622-7 [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 20073346-51
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
9 Occupational fatalities in emergency medical services a
hidden crisis
Maguire BJ1 Hunting KL Smith GS Levick NR
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 amp
total time
There were 3656 trauma patients available for analysis of whom 806 (220) died After Multivariate subgroup and instrumental analysis no significant association was found between time and mortality among injured patient(2)
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)
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)
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)
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 ie lt5 mins and lt4 mins for
patient with high risk of mortality(78)
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
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 125
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)
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
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 lsquothe right patient to the right
place at the right time to receive the right carersquo
following trauma
References 1 Lerner EB Moscati RM The golden hour
Scientific fact or medical ldquourban legendrdquo AcadEmerg Med 2001 Jul8(7)758ndash60 [Medline]
2 Newgard CD Schmicker RH Hedges JR at al Emergency medical service intervals and survival in trauma assessment of the lsquogolden hourrsquo in a North American prospective cohort Ann of Emerg Med 201055(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) doi101016jinjury201201011 (in press)
4 Tan XX Clement ND Frink M et al Pre-hospital trauma care A comparison of two healthcare systems Indian J Crit Care Med 20121622-7 [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 20073346-51
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
9 Occupational fatalities in emergency medical services a
hidden crisis
Maguire BJ1 Hunting KL Smith GS Levick NR
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)
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)
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)
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 ie lt5 mins and lt4 mins for
patient with high risk of mortality(78)
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
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 125
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)
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
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 lsquothe right patient to the right
place at the right time to receive the right carersquo
following trauma
References 1 Lerner EB Moscati RM The golden hour
Scientific fact or medical ldquourban legendrdquo AcadEmerg Med 2001 Jul8(7)758ndash60 [Medline]
2 Newgard CD Schmicker RH Hedges JR at al Emergency medical service intervals and survival in trauma assessment of the lsquogolden hourrsquo in a North American prospective cohort Ann of Emerg Med 201055(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) doi101016jinjury201201011 (in press)
4 Tan XX Clement ND Frink M et al Pre-hospital trauma care A comparison of two healthcare systems Indian J Crit Care Med 20121622-7 [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 20073346-51
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
9 Occupational fatalities in emergency medical services a
hidden crisis
Maguire BJ1 Hunting KL Smith GS Levick NR
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)
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)
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 ie lt5 mins and lt4 mins for
patient with high risk of mortality(78)
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
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 125
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)
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
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 lsquothe right patient to the right
place at the right time to receive the right carersquo
following trauma
References 1 Lerner EB Moscati RM The golden hour
Scientific fact or medical ldquourban legendrdquo AcadEmerg Med 2001 Jul8(7)758ndash60 [Medline]
2 Newgard CD Schmicker RH Hedges JR at al Emergency medical service intervals and survival in trauma assessment of the lsquogolden hourrsquo in a North American prospective cohort Ann of Emerg Med 201055(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) doi101016jinjury201201011 (in press)
4 Tan XX Clement ND Frink M et al Pre-hospital trauma care A comparison of two healthcare systems Indian J Crit Care Med 20121622-7 [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 20073346-51
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
9 Occupational fatalities in emergency medical services a
hidden crisis
Maguire BJ1 Hunting KL Smith GS Levick NR
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)
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 ie lt5 mins and lt4 mins for
patient with high risk of mortality(78)
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
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 125
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)
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
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 lsquothe right patient to the right
place at the right time to receive the right carersquo
following trauma
References 1 Lerner EB Moscati RM The golden hour
Scientific fact or medical ldquourban legendrdquo AcadEmerg Med 2001 Jul8(7)758ndash60 [Medline]
2 Newgard CD Schmicker RH Hedges JR at al Emergency medical service intervals and survival in trauma assessment of the lsquogolden hourrsquo in a North American prospective cohort Ann of Emerg Med 201055(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) doi101016jinjury201201011 (in press)
4 Tan XX Clement ND Frink M et al Pre-hospital trauma care A comparison of two healthcare systems Indian J Crit Care Med 20121622-7 [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 20073346-51
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
9 Occupational fatalities in emergency medical services a
hidden crisis
Maguire BJ1 Hunting KL Smith GS Levick NR
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 ie lt5 mins and lt4 mins for
patient with high risk of mortality(78)
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
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 125
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)
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
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 lsquothe right patient to the right
place at the right time to receive the right carersquo
following trauma
References 1 Lerner EB Moscati RM The golden hour
Scientific fact or medical ldquourban legendrdquo AcadEmerg Med 2001 Jul8(7)758ndash60 [Medline]
2 Newgard CD Schmicker RH Hedges JR at al Emergency medical service intervals and survival in trauma assessment of the lsquogolden hourrsquo in a North American prospective cohort Ann of Emerg Med 201055(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) doi101016jinjury201201011 (in press)
4 Tan XX Clement ND Frink M et al Pre-hospital trauma care A comparison of two healthcare systems Indian J Crit Care Med 20121622-7 [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 20073346-51
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
9 Occupational fatalities in emergency medical services a
hidden crisis
Maguire BJ1 Hunting KL Smith GS Levick NR
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
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 125
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)
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
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 lsquothe right patient to the right
place at the right time to receive the right carersquo
following trauma
References 1 Lerner EB Moscati RM The golden hour
Scientific fact or medical ldquourban legendrdquo AcadEmerg Med 2001 Jul8(7)758ndash60 [Medline]
2 Newgard CD Schmicker RH Hedges JR at al Emergency medical service intervals and survival in trauma assessment of the lsquogolden hourrsquo in a North American prospective cohort Ann of Emerg Med 201055(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) doi101016jinjury201201011 (in press)
4 Tan XX Clement ND Frink M et al Pre-hospital trauma care A comparison of two healthcare systems Indian J Crit Care Med 20121622-7 [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 20073346-51
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
9 Occupational fatalities in emergency medical services a
hidden crisis
Maguire BJ1 Hunting KL Smith GS Levick NR
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 125
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)
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
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 lsquothe right patient to the right
place at the right time to receive the right carersquo
following trauma
References 1 Lerner EB Moscati RM The golden hour
Scientific fact or medical ldquourban legendrdquo AcadEmerg Med 2001 Jul8(7)758ndash60 [Medline]
2 Newgard CD Schmicker RH Hedges JR at al Emergency medical service intervals and survival in trauma assessment of the lsquogolden hourrsquo in a North American prospective cohort Ann of Emerg Med 201055(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) doi101016jinjury201201011 (in press)
4 Tan XX Clement ND Frink M et al Pre-hospital trauma care A comparison of two healthcare systems Indian J Crit Care Med 20121622-7 [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 20073346-51
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
9 Occupational fatalities in emergency medical services a
hidden crisis
Maguire BJ1 Hunting KL Smith GS Levick NR
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
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 lsquothe right patient to the right
place at the right time to receive the right carersquo
following trauma
References 1 Lerner EB Moscati RM The golden hour
Scientific fact or medical ldquourban legendrdquo AcadEmerg Med 2001 Jul8(7)758ndash60 [Medline]
2 Newgard CD Schmicker RH Hedges JR at al Emergency medical service intervals and survival in trauma assessment of the lsquogolden hourrsquo in a North American prospective cohort Ann of Emerg Med 201055(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) doi101016jinjury201201011 (in press)
4 Tan XX Clement ND Frink M et al Pre-hospital trauma care A comparison of two healthcare systems Indian J Crit Care Med 20121622-7 [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 20073346-51
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
9 Occupational fatalities in emergency medical services a
hidden crisis
Maguire BJ1 Hunting KL Smith GS Levick NR
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 lsquothe right patient to the right
place at the right time to receive the right carersquo
following trauma
References 1 Lerner EB Moscati RM The golden hour
Scientific fact or medical ldquourban legendrdquo AcadEmerg Med 2001 Jul8(7)758ndash60 [Medline]
2 Newgard CD Schmicker RH Hedges JR at al Emergency medical service intervals and survival in trauma assessment of the lsquogolden hourrsquo in a North American prospective cohort Ann of Emerg Med 201055(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) doi101016jinjury201201011 (in press)
4 Tan XX Clement ND Frink M et al Pre-hospital trauma care A comparison of two healthcare systems Indian J Crit Care Med 20121622-7 [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 20073346-51
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
9 Occupational fatalities in emergency medical services a
hidden crisis
Maguire BJ1 Hunting KL Smith GS Levick NR
References 1 Lerner EB Moscati RM The golden hour
Scientific fact or medical ldquourban legendrdquo AcadEmerg Med 2001 Jul8(7)758ndash60 [Medline]
2 Newgard CD Schmicker RH Hedges JR at al Emergency medical service intervals and survival in trauma assessment of the lsquogolden hourrsquo in a North American prospective cohort Ann of Emerg Med 201055(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) doi101016jinjury201201011 (in press)
4 Tan XX Clement ND Frink M et al Pre-hospital trauma care A comparison of two healthcare systems Indian J Crit Care Med 20121622-7 [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 20073346-51
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
9 Occupational fatalities in emergency medical services a
hidden crisis
Maguire BJ1 Hunting KL Smith GS Levick NR
4 Tan XX Clement ND Frink M et al Pre-hospital trauma care A comparison of two healthcare systems Indian J Crit Care Med 20121622-7 [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 20073346-51
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
9 Occupational fatalities in emergency medical services a
hidden crisis
Maguire BJ1 Hunting KL Smith GS Levick NR