Abstract: The concept of a “golden hour” is a fixture in trauma care. There is a dearth of scientific proof for this concept but an abundance of con- Golden Hour or troversy around how this concept should be interpreted, especially for pediatric trauma patients. Health Golden care providers should instead focus on the “golden opportunity,” differ- ent for each patient, to provide the best care in the most appropriate Opportunity: environment for all injured children. Keywords: Early pediatric trauma; golden hour; pediatric emergency; trauma systems; interfacility transport Management of Pediatric Trauma

Wendalyn K. Little, MD, MPH

“There is a golden hour between life and death. If you are critically injured you have less than 60 minutes to survive. You might not die right then; it may be Pediatrics and , Divi- — sion of Pediatric Emergency Medicine, three days or two weeks later but some- Emory University School of Medicine, Chil- thing has happened in your body that is dren’s Healthcare of Atlanta, Atlanta, GA. 1 Reprint requests and correspondence: irreparable.” MD Wendalyn Little, MD, MPH, Pediatric Emer- gency Medicine, 1645 Tullie Circle, Atlanta, GA 30329. [email protected]

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THE GOLDEN HOUR improved outcomes for severely injured patients cared for in dedicated trauma centers.7,8 A core The term golden hour is a fixture in the lexicon of principal in many of these systems is the belief that trauma care. The phrase refers to a critical period critically injured patients are best cared for in in the care of trauma patients during which designated trauma centers, even if transport from appropriate care may limit morbidity and increase the field to these centers bypasses closer medical survival. The origin of this term is difficult to trace. facilities. The combination of the concepts of the It may have evolved from an early description of the golden hour and the importance of trauma centers relationship between survival and time from has been the impetus for the development of EMS to treatment on the battlefields of World War I. policies such as rapid scene , minimization of This analysis of French military data showed a on-scene treatment interventions in favor of rapid decrease in mortality from battle wounds from 10% transport to emergency departments, and air eva- within 1 hour of treatment to 75% at 8 hours post- 2 cuation of severely injured patients directly from injury. More recent medical literature often the site of injury to designated trauma centers. “ ” attributes the phrase golden hour to trauma These practices are not without cost, in money for surgeon R. Adams Cowley, MD, one of the early equipment and staffing of helicopter transport and champions of organized trauma care. Dr Cowley EMS resources. They are also not without risk to conducted trauma research and wrote and spoke EMS teams, patients, and bystanders when priority extensively on the subject of trauma care, and the is placed on rapid transport, sometimes across coining of the term golden hour is often attributed to great distances.9 A common debate in trauma his speeches, yet none of his publications mentions system development centers on whether patients or tests the theory of a golden hour in trauma 2,3 should be transferred longer distances to trauma care. Modern support for the golden hour concept centers or to the closest available facility, where began in the 1960s when trauma care in the United initial stabilization may be performed, and then States was in its infancy and civilian trauma those patients determined to need further specialty systems were nonexistent. Military data from each care are then transferred to a . Much of the world wars, the Korean Conflict and the war of the current literature supports a varied approach in Vietnam, show decreased combat mortality with based on geographic location. In urban areas, where the development of faster, more organized systems level I trauma centers are often readily available, for the transport of injured troops from the 3,4 it may make sense to bypass closer facilities to battlefield to medical care facilities. This in- reach the trauma facility, as differences in transport creased survival was attributed in part to faster times are likely to be minor. In rural areas, however, evacuation of wounded soldiers from the battlefield 4 transport times to trauma centers may be pro- to the by way of helicopter transport. The longed, and patients may benefit from stabiliza- 1960s and 1970s saw an increased interest in tion in a closer facility followed by transfer to a civilian trauma care. Federal legislation led the trauma center after initial stabilization. Effective way for funding emergency medical services (EMS) trauma systems must therefore take into account standards and training. The American College of the location and capabilities of the facilities within a Surgeons published the first of many guidelines for 4 geographic catchment area, as well as any traffic or trauma care in 1976. Pioneers such as Dr Cowley geographical features that may impact transport championed trauma care as a specialty with its 5 times. This approach to establishing effective roots in general . Helicopter transport trauma systems is perhaps best characterized by began to be seen as a means of quickly moving the “3R” rule attributed to pioneering trauma injured patients to ; some hospitals began surgeon Dr Donald Trunkey of getting the “right to devote specialized resources and teams to care patient to the right place at the right time.”10 Some for trauma victims, and the concept of regionalized patients may have only minutes to survive without trauma systems gained support from health care 4,6 appropriate intervention, whereas some may sur- providers and governing bodies. vive their initial but need specialized care and rehabilitation to achieve maximum post- TRAUMA SYSTEMS AND TRANSPORT TO injury function. This concept might well be the TRAUMA CENTERS best guiding principle of trauma management, and the immediate postinjury period might best be Early studies of trauma patients appeared to thought of as a “golden opportunity” to ensure show increased survival with the development of prompt, appropriate treatment for each and every these early trauma systems and continue to show injured patient. 6 VOL. 11, NO. 1 • GOLDEN HOUR OR GOLDEN OPPORTUNITY / LITTLE

PEDIATRIC TRAUMA AND performing procedures such as intravenous access, TRAUMA CENTERS endotracheal intubation, and appropriate cardio- pulmonary on pediatric patients.14,15 If the concept of a golden hour and its relationship There is literature to suggest similar outcomes for to trauma systems is controversial and unproven in pediatric patients ventilated by means of bagging adults, it is even more so for pediatric trauma instead of endotracheal intubation in cases of patients. The development of pediatric emergency respiratory failure, suggesting that intubation medicine as a specialty has promoted the creation of should not be attempted in the field for pediatric pediatric trauma centers, some as part of free- patients in urban locations where transport times to standing children's hospitals and others within hospital emergency departments is fairly short.15 general/adult facilities. Pediatric trauma care con- Another study examining the effectiveness of tinues to evolve as a distinct facet of trauma care pediatric helicopter transport showed no benefit that recognizes the different anatomical, physiolog- for patients transported directly from the scene of ic, and developmental realities of pediatric patients injury to a pediatric trauma center as compared as well as the different injury patterns seen in these with those initially stabilized at the closest medical patients. The development and concentration of facility.17 All of this information could be inter- pediatric expertise has improved the management preted that time spent in EMS transport of critically of injured children, with patients cared for in ill and injured children should be minimized, and pediatric trauma centers appearing to have equal these patients should be transported to the closest or better outcomes overall when compared to facility able to provide stabilizing, if not definitive, pediatric patients cared for in general or adult care. trauma centers.11-17 Many factors likely contribute to this positive effect including the availability of appropriately sized equipment and monitoring READINESS capabilities for pediatric patients, health care FOR CHILDREN providers capable of recognizing and treating the early, often subtle, signs of in pediatric If pediatric patients are to be transported to non– patients, and management strategies unique to pediatric-specific hospitals, the emergency depart- pediatric injuries. ments at these facilities must be capable of assessing Despite evidence to suggest better outcomes for pediatric trauma patients and providing stabilizing pediatric trauma victims treated in pediatric trauma care (also see article “Pediatric Patients in the Adult centers, most pediatric trauma victims are cared Trauma Bay—Comfort Level and Challenges,” in for, at least initially, in nonpediatric centers, as the this issue). Although most emergency department number and geographic location of dedicated visits in the United States involving children occur pediatric centers leaves many children out of in nonpediatric facilities, many of these facilities are reach for immediate care.12,13 The question that underprepared to deal with critically ill or injured therefore arises is not only does a golden hour exist children. In 2001, the American Academy of for the treatment of pediatric trauma patients, but Pediatrics and the American College of Emergency also, what should occur during that initial time Physicians established a set of guidelines for frame. One aspect of this debate centers on whether pediatric emergency department preparedness.18 pediatric trauma patients should be transported These guidelines, which were recently updated in directly to pediatric centers, possibly bypassing 2009, address equipment, training, and quality other emergency facilities or trauma centers on review for pediatric care in emergency depart- the way to specialized pediatric care, or should they ments.19,21 Surveys evaluating preparedness con- be stabilized at the closest capable facility and then tinue to show inadequate preparation in equipment transferred to specialized pediatric centers if their and training for pediatric patients.13,20,22 Nonpedia- condition warrants. It is worrisome that pediatric tric centers often transfer seriously ill or injured patients may be subjected to longer transport times, patients to pediatric centers for definitive care. The possibly bypassing “adult” trauma facilities to reach presence of a seriously injured child may engender a pediatric centers, as EMS providers often do not sense of anxiety in the emergency department and have great familiarity or experience with critically ill has the potential to create a stress-laden atmo- or injured children. The EMS pediatric volumes are sphere in which recognition and treatment of life- often quoted as around 10% of EMS calls, with less threatening shock and respiratory failure go unad- than 1% of these patients meeting the definition of dressed and untreated in attempts to get the patient critically ill. The EMS personnel may have difficulty out of the facility and enroute to a pediatric GOLDEN HOUR OR GOLDEN OPPORTUNITY / LITTLE • VOL. 11, NO. 1 7 specialty center as quickly as possible. Missed threatening hemorrhage would seem to be candi- injuries on an initial trauma survey are a common dates for immediate transfer to a trauma center with problem, and there is some evidence from adult pediatric surgeons and a pediatric intensive care studies that seriously injured patients transferred unit but at times may require the services of a from rural hospitals to trauma centers frequently general surgeon, if available, to control hemorrhage have unrecognized injuries.23,24 This suggests that before transport. Most pediatric trauma is caused by patients may have injuries overlooked in favor of blunt mechanism of injury such as falls, motor rapid transport to a trauma center. This problem vehicle collisions, assault, and sporting activities. may be even more widespread for pediatric patients Most patients will not require emergent surgical in similar situations. Recent literature supports intervention. Pediatric trauma specialists have led early recognition and treatment of shock and the development of protocols for expectant, nonop- respiratory failure as important in improving ulti- erative management of some conditions, namely mate survival and outcome of critically ill or injured liver and splenic injuries. In adult-oriented systems, patients, both adult and pediatric.25,26 Similarly, these injuries are generally treated surgically, neurologic outcome has been shown to improve whereas children cared for in pediatric centers are with early appropriate resuscitation and monitoring usually managed nonoperatively. Therefore, pediat- of children with .27 Unfortu- ric patients undergo fewer laparotomies and sple- nately, studies of pediatric patients transferred to nectomies than do adult patients.29,30 The golden pediatric centers describe deficiencies in the detec- hour for these patients might best be spent ensuring tion and treatment of shock, hypotension, and adequate oxygenation and ventilation, securing an respiratory failure before transfer.18,25,26 airway if needed, obtaining vascular access, and providing initial fluid resuscitation if needed. Patients with traumatic brain injury must be INITIAL STABILIZATION OF carefully monitored, and hypotension and hypoxia INJURED CHILDREN avoided as both of these states have been found to be independent predictors of increased mortality in So what should be the scope of the evaluation and patients with traumatic brain injury. Pediatric stabilization of pediatric trauma patients in general patients with isolated brain injuries may best be trauma facilities or community hospitals? A prima- stabilized at the closest medical facility in which ry survey focusing on airway, breathing, and these conditions may be recognized and corrected circulation should be undertaken and any life- as needed. Transport could then be undertaken in a threatening conditions corrected. All patients controlled fashion and preferably with a specialized should be placed on supplemental oxygen. Ad- pediatric critical care transport team. Time should vanced in the form of endotra- not be spent obtaining computerized tomography cheal intubation may be needed in patients with and other extensive imaging studies if the facility severe traumatic brain injury, thoracic injuries, or lacks the surgical capabilities to provide definitive shock. Adequate oxygenation and ventilation should care for injuries detected on imaging or if obtaining be ensured. A portable chest radiograph to evaluate scans will delay transport. Scans may inadvertently for pneumothorax may be helpful. Placement of a fail to be transported with the patient or, in the case thoracostomy tube should be pursued for most cases of digital images, transferred by compact disk, of pneumothorax. Close attention should be paid to inaccessible at the receiving facility, thus, necessi- the child's hemodynamic status. Health care provi- tating repeat imaging with increased costs and ders must keep in mind that the strong compensa- unnecessary radiation exposure to the patient. In tory mechanisms in children and teenagers allow fact, one study found that almost all radiographs them to increase their systemic vascular resistance performed at referring facilities were later repeated and maintain blood pressure until a substantial when patients arrived to the trauma center.31 amount of blood is lost.19,28 Early signs of shock Once critically ill or injured children are stabi- such as tachycardia, mental status, and capillary lized and the decision is made to transfer to a refill time are more sensitive and should be pediatric trauma center, attention must then be monitored closely. An initial fluid bolus of isotonic turned to the best mode of transfer. One recent saline should be administered and repeated as study showed significantly more complications and needed. Blood component transfusion should be deaths (23% mortality vs 9% mortality) among considered for patients not responding to crystalloid pediatric patients transferred from referring facili- resuscitation or for those with evidence of ongoing ties to a pediatric trauma center by “general” hemorrhage.27 Patients with immediately life- helicopter teams vs specialized pediatric teams. 8 VOL. 11, NO. 1 • GOLDEN HOUR OR GOLDEN OPPORTUNITY / LITTLE

This remained true even when corrected for patient ongoing treatment vs “awaiting transfer” and be mix and the greater average time from referral to capable of recognizing and responding to evolving arrival in the pediatric center among patients clinical changes in pediatric patients. transported by the specialty teams. The authors speculate that despite overall longer transport times, the patients transported by the specialized SUMMARY team actually benefited from an overall longer Certainly, no one would argue that timely care is 18 period in the care of pediatric specialists. This best for critically ill and injured persons. However, “ ” concept of bringing the hospital to the patient may the exact meaning and significance of a golden hour in fact be a critical piece of care that is currently in trauma care is the subject of debate and lacking in many trauma systems. Several studies controversy. So is there a golden hour? If there is, have shown that transport by specialty-trained then what should occur during this time? Should “ ” mobile intensive care unit teams is associated this time be spent transferring a patient from the with improved outcomes, even if such transport scene to a center, even if it is not the delays ultimate patient arrival at the tertiary care closest facility? Or should patients be stabilized at 18,19, 28-44 center. the closest medical facility before transfer? Fur- thermore, how do the concepts of a golden hour and THE GOLDEN OPPORTUNITY trauma system care apply to pediatric patients? Perhaps, the answers lie somewhere in between, So what is the best care for pediatric trauma and rather than a golden hour, health care patients? How can a system capitalize on the providers should focus on the “golden opportunity” “ ” golden opportunity to provide the right care in to provide stabilization of immediately life-threat- the right place at the right time? Creation of ening conditions at the closest appropriate facility regionalized trauma systems to ensure timely access followed by safe transfer when needed for definitive to basic evaluation and stabilization for all patients care. True realization of this opportunity for 45 is vital. This may require initial transport of pediatric trauma patients requires individualized pediatric trauma patients to general emergency consideration for each patient within well-estab- facilities, especially in rural areas without immedi- lished and well-coordinated systems of regionalized ately available pediatric trauma centers. These trauma care. facilities must be capable of evaluating and stabiliz- ing pediatric trauma patients. Appropriately sized equipment and monitoring capabilities must be REFERENCES present. Staff must have skills in the assessment and stabilization of pediatric patients, especially in 1. www.umm.edu/shocktrauma/history.htm. 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