The Golden Hour in Acute Head Injury
The “Golden Hour” is one of those topic in EMS which people feel very strongly about. Plenty of research exists on both sides of the issue and further studies are released all the time which tend to compound the issue rather than clarify it. The Golden Hour, to review, is the time interval said to be linked with survival of a traumatic injury and is measure from the time of injury until the patient receives surgical intervention. The idea, of course, is that getting a patient to surgery within an hour will improve outcomes. It is important to note, however, that there a certain subset of trauma patients who have fatal injuries regardless of time to intervention, sometimes it is just your day to go.
A study was released recently for Injury looking at what might be a grey area in the argument about the Golden Hour: severe head injury. Let’s take a look at the abstract:
Injury. 2012 Feb 13. [Epub ahead of print]
Redefining the golden hour for severe head injury in an urban setting: The effect of prehospital arrival times on patient outcomes.
Dinh MM, Bein K, Roncal S, Byrne CM, Petchell J, Brennan J.
Royal Prince Alfred Hospital, Trauma Office level 10, Missenden Road, Camperdown, NSW 2050, Australia.
BACKGROUND: In patients with severe head injuries, transportation to a trauma centre within the “golden hour” are important markers of trauma system effectiveness but evidence regarding impacts on patient outcomes is limited.
OBJECTIVE: To determine the effect of patient arrival within the golden hour on patient outcomes.
METHODS: A retrospective cohort of adult patients with severe head injuries (head AIS≥3) arriving within 24h of injury was identified using the trauma registry from 2000 to 2011. Survival analysis was used to determine the effect of patient arrival time on overall mortality. Study outcomes were in hospital mortality and survival to hospital discharge without requiring transfer for ongoing rehabilitation or nursing home care.
RESULTS: There was a significant association with mortality with each incremental minute of patient arrival (HR 1.002, 95%CI 1.001-1.004, p=0.001). There was however no survival benefit observed for patients arriving within 60min of injury time (HR 0.77, 95%CI 0.50-1.18, p=0.22) but an apparent benefit for those presenting within 2h of injury time (HR 0.31, 95%CI 0.15-0.66, p=0.002). Patient arrival within 60min of injury time was associated with increased odds of survival to hospital discharge without requiring ongoing rehabilitation (OR 1.78, 95%CI 1.14-2.79, p=0.01).
CONCLUSION: 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 60min of injury time.
So what’s your take? First of all, let me say that I am pleased to see more researchers looking at patients who are surviving illness and injury AND retaining functionality. Simply surviving a head injury or cardiac arrest but being unable to function at all should not be considered a success of medicine. The patient who survived AND did not require ongoing rehabilitation were counted an analyzed.
Second, this is looking at an urban trauma system. Given the prevalence of research and teaching institutions in urban centers, this type of research tends to be focused there. I am in an urban system so this is useful for me, but it would be nice to see more research targeted at rural trauma patients.
Third, the results are fairly interesting. Patients appear to be more likely to survive if treated within the first two hours. They are more likely, however, to be discharged functionally intact if treated within the first 60 minutes. Sounds like the “Golden Hour” may work here. There was, though, no benefit associated with treatment before 60 minutes.
So what does this all mean? Clearly, severe head injury patients are time sensitive. For the purposes of this study, however, that only means that they are seen within one hour of their time of injury. There is no noted benefit to being seen before then. Perhaps these patients fall into the growing category of those who do not require “lights and sirens” transport. If these patients are maintaining an airway and vital signs, maybe we can forgo the risk of running code into the hospital? What do you think? Let me know in the comments.