Medicine is full of “golden” times. tPA, door-to-balloon time, sepsis bundles, and more – as the various time-dependent mandates pile up and resources remain static, it is important to revisit each and prioritize.
These authors are making an observational comment on the “golden hour” as it applies to seriously injured trauma patients. Modern trauma systems have evolved to rapidly funnel patients through the system to the best-equipped facility. This has involved significant investment and resource utilization by aeromedical transport. While glamorous and heroic, unfortunately many patients transported by this inefficient and dangerous method are either too lightly or badly damaged to demonstrate any benefit from alacrity.
These authors, looking at data from a clinical trial concerning early resuscitation fluids, analyze 778 patients with hemorrhagic shock and 1,239 patients with traumatic brain injury. Patients whose pre-hospital time exceeded 60 minutes – the “golden hour” – were no more likely to be dead or neurologically devastated than those who reached the hospital within 60 minutes. Thus, questioning the “golden hour” of trauma.
However, at least, within the hemorrhagic shock group, the subset of 484 patients in which a “critical intervention” was performed within 24 hours of arrival did show a survival advantage – OR 2.37 (95% CI 1.05 to 5.37). It is probably still reasonable to continue transporting those in hypovolemic shock until validated criteria for non-survivability or lack of intervention exist. Traumatic brain injury patients, however, may urgently need to be revisited for the necessity of resource-intensive transport.
This is, additionally, a lovely example of secondary use of clinical trial data. Even though the original trial was stopped early due to futility regarding the primary efficacy endpoint, the re-use of the rigorously collected data redeems the invested resources. High-quality clinical trial data is accumulating rapidly – and perhaps the greatest tragedy in medicine is how much it is locked away as proprietary intellectual property. Share! Share!
“Revisiting the ‘Golden Hour’: An Evaluation of Out-of-Hospital Time in Shock and Traumatic Brain Injury”
http://www.ncbi.nlm.nih.gov/pubmed/25596960