Lecture 4 Feb 27, 2018

THE GOLDEN HOUR OF TRAUMA

DAVID KALB, MD MERCY , COON RAPIDS, MN

DR.

• July 25, 1917 – October 27,1991 • American surgeon • Pioneer in and trauma care • “Father of Trauma Medicine” • Founder of U.S’s first at U of MD, 1958 • Leader in use of helicopters for med evac of civilians, from 1969 • Founded the nation’s first statewide EMS system in 1972

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DR. R ADAMS COWLEY

GOLDEN HOUR

• Coined by Dr. Cowley • “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 three days or two weeks later – but something has happened to your body that is irreparable.” (from U of MD website) • “the first hour after will largely determine a critically-injured person’s chances for survival” (MD State Medical Journal 1975)

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GOLDEN HOUR

GOLDEN HOUR

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•What does the data show??

EVIDENCE IN FAVOR OF THE GOLDEN HOUR

• 1993 Journal of Trauma Sampalis et al • Total prehospital time over 60 minutes was associated with significant increase in odds of mortality • 1999 Journal of Trauma Sampalis et al • Reduced prehospital time associated with reduced odds of dying • When outcomes controlled for • Severity of injury • Age of population

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EVIDENCE IN FAVOR OF THE GOLDEN HOUR

• Acad Emerg Med 2002 Blackwell et al • EMS response times less than 5 minutes associated with improved survival • Cohort of both life threatening and non-life threatening EMS calls • Acad Emerg Med 2005 Pons et al • EMS response times less than 4 minutes resulted in survival benefit for patients with intermediate or high risk of mortality • Looked at EMS response times, not total prehospital time • Looked at mixed populations

EVIDENCE AGAINST THE GOLDEN HOUR

• Ann Emerg Med 2010 Newgard et al • Prospective study of 146 EMS agencies transporting patients to 51 trauma centers in North America • No relationship between EMS intervals and in-hospital mortality • Finding persisted across several subgroups • Injury type • Age • Mode of transport

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ANN EMERG MED 2010 NEWGARD ET AL

• 3656 patients evaluated • Sick patients! • SBP less than or equal to 90 • RR less than 10 or greater than 29 • GCS less than or equal to 12 • Need for advanced airway intervention

ANN EMERG MED 2010 NEWGARD ET AL

• Overall mortality 22% • No significant association between time and mortality for any EMS interval • Response time • On-scene duration • Transport time • Total EMS time • Level of , mode of transport

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ANN EMERG MED 2010 NEWGARD ET AL

ANN EMERG MED 2010 NEWGARD ET AL

• Divided patients into quartiles based on total EMS time • Divided patients into less than vs. greater than 60 minutes total EMS time

• No difference in survival!!!

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ANN EMERG MED 2010 NEWGARD ET AL

• “Although it is likely that minutes do affect outcome for certain severely injured individuals, demonstrating this relationship across a field-defined population of injured persons using EMS intervals has generally produced inconclusive results.” • Criticized Quebec studies as retrospective, and not reproducible. • Acknowledged that having a trauma system reliably proven to decrease mortality. • Time to hospital based intervention more important than transport time??

ANN EMERG MED 2015 NEWGARD ET AL

• Looked at 778 patients with and/or TBI from previous study population • Out of hospital time greater than 60 minutes not associated with worse outcomes • Subgroup of patients with shock and TBI requiring “early critical hospital resources” • Within 24 hours of ED arrival • PRBC greater than or equal 6 Units • Major nonorthopedic surgical procedures • IR procedures • death

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ANN EMERG MED 2015 NEWGARD ET AL

• Subgroup of shock patients arriving at trauma center greater than 60 minutes from 911 call more likely to die within 28 days • Patients with TBI did not demonstrate similar association

EVIDENCE AGAINST THE GOLDEN HOUR

• Unfallchirug 2013 Kleber et al • No significant survival advantage for trauma patients with shorter prehospital times • CMAJ 2008 Steill et al • No significant survival advantage in trauma patients cared for by EMS providers • • Advanced life support • Ann Emerg Med Pepe et al • No significant survival advantage with shorter prehospital times in patients with penetrating injury and shock

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• Prehosp Disaster Med 1995 Petri et al EVIDENCE • Acad Emerg Med 2003 Lerner et al AGAINST THE GOLDEN HOUR • J Emerg Med 2002 Pons et al • Injury 2007 Di Bartolomeo et al

WHY DOES IT MATTER???

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WHY DOES IT MATTER???

• 2010 Chung et al • Looked at quality of chest compressions in ambulances at variable speeds • Used CPR mannequin • Higher speeds correlated with lower quality compressions

WHY DOES IT MATTER???

• EMS workers have documented fatality rate of 12.7/100,000 per year • Over twice national average of 5/100,000 • By some estimates, subgroup of transportation related to EMS workers and their patients may be 5 x national average risk of transit related injury • Deaths and injuries largely attributed • Helicopter and ambulance crashes • Result from emphasis on shorter pre-hospital time frames.

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WHY DOES IT MATTER???

• Cost – Hard to quantify • Every EMS system is different nationwide, no standardization • Not all insurance covers it, out of pocket charges hard to tally • Hard to separate trauma EMS charges from other uses • Medicare notes in 2013 $6 billion a year for ambulance rides • True # is likely more impressive considering medicare has fixed payments for ambulances • Far less than commercial rates

PERSPECTIVES

• Sometimes things that make 100% sense to our intuition aren’t correct, or aren’t correct for the reasons we think • Beware the proclamation by gurus!

• There are limitations to evaluations of significance of golden hour • Multiple time periods that can be evaluated • Different contexts in which the golden hour can be evaluated • Time of injury and death can be inconsistently recorded

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PERSPECTIVES

• Misinterpretation of data by hospital administrators • “proof” of data supports decreasing or eliminating investment in timely care of trauma patients • Great misfortune for patients • EMS transport time DOES help certain patients (cardiac arrest, MI, stroke) • NEJM 2006 MacKenzie et al • When designate as a trauma center, trauma-related mortality drops by 25% • Robust EMS is PART of trauma center care

PERSPECTIVES

• Timely EMS care is a part of credentialing as a trauma center • Trauma patients do better at a trauma center • When you pull out the EMS times by themselves, no significant advantage is seen with quicker transport per recent literature. • EMS care itself is temporizing the care of the patient • “mobile emergency departments”

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FURTHER DIRECTIONS

1 2 3

Drill down on Look further at Look further at air specific specific subsets of vs. ground transport interventions used trauma patients for trauma patients by EMS • Ideal distance

THANK YOU FOR YOUR TIME!

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